{"component": "clause", "props": {"groups": [{"snippet": "The Contractor shall not avoid costs for services covered under this contract by referring Enrollees to publicly supported health care resources.", "size": 8, "samples": [{"hash": "4T5YNlRXFnS", "uri": "/contracts/4T5YNlRXFnS#cost-avoidance", "label": "Premier Access Contract Prepaid Ambulatory Health Plan (Pahp)", "score": 33.485133533, "published": true}, {"hash": "2qHJXbql76O", "uri": "/contracts/2qHJXbql76O#cost-avoidance", "label": "McNa Dental Contract", "score": 33.485133533, "published": true}, {"hash": "juzv09d1bMc", "uri": "/contracts/juzv09d1bMc#cost-avoidance", "label": "Premier Access Chip Contract", "score": 33.4741840627, "published": true}], "snippet_links": [{"key": "the-contractor-shall", "type": "clause", "offset": [0, 20]}, {"key": "services-covered", "type": "clause", "offset": [41, 57]}, {"key": "under-this-contract", "type": "clause", "offset": [58, 77]}, {"key": "publicly-supported", "type": "definition", "offset": [104, 122]}, {"key": "health-care", "type": "definition", "offset": [123, 134]}], "hash": "20ed1847517e4d9d8ea9c1ffe4de4cdb", "id": 1}, {"snippet": "As provided in Article 8.7, except in certain cases, the Contractor shall attempt to avoid payment in all cases where there is other insurance.", "size": 6, "samples": [{"hash": "aHtSsPKYnCG", "uri": "/contracts/aHtSsPKYnCG#cost-avoidance", "label": "Contract to Provide Services", "score": 24.5167693361, "published": true}, {"hash": "dPqIQof5svH", "uri": "/contracts/dPqIQof5svH#cost-avoidance", "label": "Contract to Provide Services", "score": 23.9828884326, "published": true}, {"hash": "faNCaPkV0Gg", "uri": "/contracts/faNCaPkV0Gg#cost-avoidance", "label": "Contract to Provide Services", "score": 23.4845995893, "published": true}], "snippet_links": [{"key": "in-certain-cases", "type": "definition", "offset": [35, 51]}, {"key": "the-contractor-shall", "type": "clause", "offset": [53, 73]}, {"key": "in-all-cases", "type": "clause", "offset": [99, 111]}, {"key": "other-insurance", "type": "definition", "offset": [127, 142]}], "hash": "463937d8a553a3bcb59e161e27624f72", "id": 2}, {"snippet": "8.4.2.1 The Contractor shall cost avoid all Claims or services that are subject to payment from a third party health insurance carrier, and may deny a service to a Member if the Contractor is assured that the third party health insurance carrier will provide the service, with the exception of those situations described below in Section 8.4.", "size": 5, "samples": [{"hash": "jijP08Dmgxz", "uri": "/contracts/jijP08Dmgxz#cost-avoidance", "label": "Contract for Provision of Services (Wellcare Health Plans, Inc.)", "score": 24.1279945243, "published": true}, {"hash": "3i7aNAOrfQN", "uri": "/contracts/3i7aNAOrfQN#cost-avoidance", "label": "Contract (Wellcare Health Plans, Inc.)", "score": 20.1252566735, "published": true}], "snippet_links": [{"key": "the-contractor-shall", "type": "clause", "offset": [8, 28]}, {"key": "cost-avoid", "type": "definition", "offset": [29, 39]}, {"key": "all-claims", "type": "clause", "offset": [40, 50]}, {"key": "subject-to", "type": "definition", "offset": [72, 82]}, {"key": "a-third-party", "type": "clause", "offset": [96, 109]}, {"key": "health-insurance-carrier", "type": "clause", "offset": [110, 134]}, {"key": "a-member", "type": "clause", "offset": [162, 170]}, {"key": "if-the-contractor", "type": "clause", "offset": [171, 188]}, {"key": "the-third-party", "type": "definition", "offset": [205, 220]}, {"key": "the-service", "type": "clause", "offset": [259, 270]}, {"key": "with-the-exception-of", "type": "clause", "offset": [272, 293]}, {"key": "section-84", "type": "clause", "offset": [330, 341]}], "hash": "f1c926ddb2cd629b54bb50bd6145cfc3", "id": 3}, {"snippet": "22.4.5.1 When the Contractor is aware of health or casualty insurance coverage before paying for a Covered Service, the Contractor shall avoid payment by promptly (within fifteen (15) Business Days of receipt) rejecting the Provider\u2019s claim and directing that the Claim be submitted first to the appropriate Third Party.", "size": 4, "samples": [{"hash": "9XoR0rtEeGq", "uri": "/contracts/9XoR0rtEeGq#cost-avoidance", "label": "Contract for Health Services Administration (Triple-S Management Corp)", "score": 22.8097193703, "published": true}, {"hash": "5fxg7KKlAsp", "uri": "/contracts/5fxg7KKlAsp#cost-avoidance", "label": "Contract for Administration of Health Services (Triple-S Management Corp)", "score": 20.839835729, "published": true}], "snippet_links": [{"key": "insurance-coverage", "type": "clause", "offset": [60, 78]}, {"key": "before-paying", "type": "clause", "offset": [79, 92]}, {"key": "covered-service", "type": "definition", "offset": [99, 114]}, {"key": "the-contractor-shall", "type": "clause", "offset": [116, 136]}, {"key": "payment-by", "type": "clause", "offset": [143, 153]}, {"key": "business-days-of-receipt", "type": "clause", "offset": [184, 208]}, {"key": "the-provider", "type": "clause", "offset": [220, 232]}, {"key": "the-claim", "type": "definition", "offset": [260, 269]}, {"key": "third-party", "type": "clause", "offset": [308, 319]}], "hash": "679898641628177f342910bffcee51e6", "id": 4}, {"snippet": "As provided in Article 8.13, except in certain cases, the contractor shall attempt to avoid payment in all cases where there is other insurance. The system should have edits to identify potential other coverage situations and flag the claims accordingly. The edits should include looking for accident indicators, other coverage information from the claims, other coverage information on file for the enrollee, and potential accident/injury diagnoses.", "size": 3, "samples": [{"hash": "kzHkpJrSlyT", "uri": "/contracts/kzHkpJrSlyT#cost-avoidance", "label": "Contract to Provide Services (Amerigroup Corp)", "score": 18.0, "published": true}, {"hash": "bytvGgaSGDy", "uri": "/contracts/bytvGgaSGDy#cost-avoidance", "label": "Contract to Provide Services (Centene Corp)", "score": 18.0, "published": true}, {"hash": "5kmTsOxlEY4", "uri": "/contracts/5kmTsOxlEY4#cost-avoidance", "label": "Contract to Provide Services (Americhoice Corp)", "score": 16.0, "published": true}], "snippet_links": [{"key": "in-certain-cases", "type": "definition", "offset": [36, 52]}, {"key": "the-contractor-shall", "type": "clause", "offset": [54, 74]}, {"key": "in-all-cases", "type": "clause", "offset": [100, 112]}, {"key": "other-insurance", "type": "definition", "offset": [128, 143]}, {"key": "the-system", "type": "definition", "offset": [145, 155]}, {"key": "the-claims", "type": "clause", "offset": [231, 241]}, {"key": "information-from", "type": "clause", "offset": [328, 344]}, {"key": "on-file", "type": "clause", "offset": [384, 391]}], "hash": "0a3b424bc5356206ead9bbd01cc916bd", "id": 5}, {"snippet": "1. When the contractor is aware of health or casualty insurance coverage prior to paying for a health care service, it shall avoid payment by rejecting a provider's claim and directing that the claim be submitted first to the appropriate third party, or by directing its provider to withhold payments to a subcontractor.\n2. If insurance coverage is not available, or if one of the exceptions to the cost avoidance rule discussed below applies, then payment must be made and a claim made against the third party, if it is determined that the third party is or may be liable.", "size": 3, "samples": [{"hash": "kzHkpJrSlyT", "uri": "/contracts/kzHkpJrSlyT#cost-avoidance", "label": "Contract to Provide Services (Amerigroup Corp)", "score": 18.0, "published": true}, {"hash": "bytvGgaSGDy", "uri": "/contracts/bytvGgaSGDy#cost-avoidance", "label": "Contract to Provide Services (Centene Corp)", "score": 18.0, "published": true}, {"hash": "5kmTsOxlEY4", "uri": "/contracts/5kmTsOxlEY4#cost-avoidance", "label": "Contract to Provide Services (Americhoice Corp)", "score": 16.0, "published": true}], "snippet_links": [{"key": "the-contractor", "type": "clause", "offset": [8, 22]}, {"key": "insurance-coverage", "type": "clause", "offset": [54, 72]}, {"key": "prior-to", "type": "definition", "offset": [73, 81]}, {"key": "health-care-service", "type": "definition", "offset": [95, 114]}, {"key": "payment-by", "type": "clause", "offset": [131, 141]}, {"key": "the-claim", "type": "definition", "offset": [190, 199]}, {"key": "payments-to", "type": "definition", "offset": [292, 303]}, {"key": "a-subcontractor", "type": "definition", "offset": [304, 319]}, {"key": "not-available", "type": "definition", "offset": [349, 362]}, {"key": "exceptions-to-the-cost-avoidance-rule", "type": "clause", "offset": [381, 418]}, {"key": "the-third-party", "type": "definition", "offset": [495, 510]}], "hash": "5bd70f3207c5631de90aa3e719b63c65", "id": 6}, {"snippet": "The Contractor shall take reasonable measures to determine all legally liable parties. This refers to any individual, entity or program that is or may be liable to pay all or part of the expenditures for covered services. The Contractor shall cost-avoid a claim if it has established the probable existence of a liable party at the time the claim is filed. Establishing liability takes place when the Contractor receives confirmation that another party is, by statute, contract, or agreement, legally responsible for the payment of a claim for a healthcare item or service delivered to a member. If the probable existence of a party\u2019s liability cannot be established the Contractor must adjudicate the claim. The Contractor must then utilize post payment recovery which is described in further detail below. If AHCCCS determines that the Contractor is not actively engaged in cost avoidance activities the Contractor shall be subject to sanctions.", "size": 2, "samples": [{"hash": "cVXBQxwGRIP", "uri": "/contracts/cVXBQxwGRIP#cost-avoidance", "label": "Intergovernmental Agreement", "score": 22.7301711785, "published": true}, {"hash": "ioeJyiS8V0D", "uri": "/contracts/ioeJyiS8V0D#cost-avoidance", "label": "Intergovernmental Agreement", "score": 21.9746577264, "published": true}], "snippet_links": [{"key": "the-contractor-shall", "type": "clause", "offset": [0, 20]}, {"key": "to-determine", "type": "definition", "offset": [46, 58]}, {"key": "liable-parties", "type": "definition", "offset": [71, 85]}, {"key": "to-pay", "type": "clause", "offset": [161, 167]}, {"key": "covered-services", "type": "definition", "offset": [204, 220]}, {"key": "liable-party", "type": "definition", "offset": [312, 324]}, {"key": "at-the-time", "type": "clause", "offset": [325, 336]}, {"key": "claim-is-filed", "type": "clause", "offset": [341, 355]}, {"key": "another-party", "type": "definition", "offset": [439, 452]}, {"key": "responsible-for", "type": "clause", "offset": [501, 516]}, {"key": "payment-of", "type": "definition", "offset": [521, 531]}, {"key": "item-or-service", "type": "definition", "offset": [557, 572]}, {"key": "a-member", "type": "clause", "offset": [586, 594]}, {"key": "a-party", "type": "clause", "offset": [625, 632]}, {"key": "the-contractor-must", "type": "clause", "offset": [667, 686]}, {"key": "post-payment", "type": "clause", "offset": [742, 754]}, {"key": "further-detail", "type": "clause", "offset": [786, 800]}, {"key": "engaged-in", "type": "definition", "offset": [865, 875]}, {"key": "cost-avoidance-activities", "type": "clause", "offset": [876, 901]}, {"key": "subject-to-sanctions", "type": "definition", "offset": [926, 946]}], "hash": "c6758cb20659ee4a02db589dd4030ec7", "id": 7}, {"snippet": "Indicate the dollar amount you denied as a result of your knowledge of other insurance that is available for the enrollee. Amount Cost Avoided:", "size": 2, "samples": [{"hash": "kQs4JVJN31q", "uri": "/contracts/kQs4JVJN31q#cost-avoidance", "label": "Contract for Medicaid and Badgercare Hmo Services (Centene Corp)", "score": 21.0, "published": true}, {"hash": "70m3HZ9zOEd", "uri": "/contracts/70m3HZ9zOEd#cost-avoidance", "label": "Contract for Medicaid and Badgercare Hmo Services (Centene Corp)", "score": 21.0, "published": true}], "snippet_links": [{"key": "dollar-amount", "type": "clause", "offset": [13, 26]}, {"key": "knowledge-of", "type": "clause", "offset": [58, 70]}, {"key": "other-insurance", "type": "definition", "offset": [71, 86]}], "hash": "7c60b978d831f8c6e93cf8c1393cc780", "id": 8}, {"snippet": "In accordance with Department requirements in the Managed Care Policy and Procedure Guide, the CONTRACTOR must have processes, methods and resources necessary to receive TPL data from the Department and to identify third-party coverage for its members. This information will be used in managing Provider payment at the front end before the Claim is paid. The CONTRACTOR must have appropriate edits in the Claims system to ensure that Claims are properly coordinated when other insurance is identified. The CONTRACTOR\u2019s Medicaid reimbursement and Third Party payment cannot exceed the amount the Provider has agreed to accept as payment in full from the Third Party payer. If the probable existence of TPL has been established at the time the Claim is filed, the CONTRACTOR must reject the Claim and return it to the Provider for a determination of the amount of any TPL. The CONTRACTOR shall \u2587\u2587\u2587\u2587 or inform the Provider to \u2587\u2587\u2587\u2587 the third-party coverage within thirty (30) Days of identification. For certain services, the CONTRACTOR should not cost-avoid Claims and will pursue recovery under a policy known as \u201cPay & Chase\u201d. See the Managed Care Policy and Procedure Guide for list of services. While Providers of such services are encouraged to file with any liable Third Party before the CONTRACTOR, if they choose not to do so, the CONTRACTOR will pay the Claims and \u2587\u2587\u2587\u2587 liable Third Parties directly through a Benefit Recovery Program. The CONTRACTOR shall deny payment on a Claim that has been denied by a known Third Party payer, as defined in Section 10 of this contract, when the reason for denial is the Provider or Medicaid Managed Care Member\u2019s failure to follow prescribed Procedures, including but not limited to, failure to obtain Prior Authorization, timely filing, etc. Post-Payment Recovery Post-payment recovery is necessary in cases where the CONTRACTOR has not established the probable existence of a liable Third Party at the time services were rendered or paid for, for members who become retroactively eligible for Medicare, or in situations when the CONTRACTOR was unable to cost-avoid. The CONTRACTOR must have Procedures in place to ensure that a Provider who has been paid by the CONTRACTOR and subsequently receives reimbursement from a Third Party repays the CONTRACTOR either the full amount paid by Medicaid or the full amount paid by the Third Party, whichever is less. CONTRACTOR Post-Payment Recovery Requirements In accordance with Department requirements in the Managed Care Policy and Procedure Guide, the CONTRACTOR must have established Procedures for recouping post-payment. The Procedures must be available for review upon request by the Department. The CONTRACTOR must void Encounters for Claims that are recouped in full. The CONTRACTOR will submit a replacement Encounter for Recoupments that result in an adjusted Claim value. The CONTRACTOR shall seek reimbursement in accident/trauma-related cases when Claims in the aggregate equal or exceed $250. The CONTRACTOR shall report all recoveries it collects outside of the Claims processing system, including settlements. The CONTRACTOR shall treat such recoveries as offsets to medical expenses for the purposes of reporting. Retroactive Eligibility for Medicare The Department or its designee will notify the CONTRACTOR when Medicaid Managed Care Members become retroactively eligible for Medicare. The Department will recoup premium payments that do not reflect the dual status of the member. The Managed Care Policy and Procedure Guide provides specific Procedures for Subcontractor Recoupment of Medicaid payments while the member had dual Medicare and Medicaid coverage. Third-Party Liability Reporting Disenrollment Requests The CONTRACTOR must submit a Disenrollment request if it has identified the presence of Third Party resource that results in the individual\u2019s being ineligible for Enrollment in CONTRACTOR\u2019s Health Plan. Third-Party Liability Recoveries by the Department After one hundred and eighty (180) Days from the date of payment of a Claim subject to recovery, the Department reserves the right to attempt recovery independent of any action by the CONTRACTOR. The Department will retain all funds received as a result of any state-initiated recovery or Subrogation action.", "size": 2, "samples": [{"hash": "3lDOtumFyQW", "uri": "/contracts/3lDOtumFyQW#cost-avoidance", "label": "Contract for Medical Services", "score": 24.1704312115, "published": true}], "snippet_links": [{"key": "in-accordance-with", "type": "definition", "offset": [0, 18]}, {"key": "department-requirements", "type": "clause", "offset": [19, 42]}, {"key": "policy-and-procedure", "type": "clause", "offset": [63, 83]}, {"key": "the-contractor-must", "type": "clause", "offset": [91, 110]}, {"key": "to-receive", "type": "definition", "offset": [159, 169]}, {"key": "coverage-for", "type": "clause", "offset": [227, 239]}, {"key": "provider-payment", "type": "definition", "offset": [295, 311]}, {"key": "front-end", "type": "clause", "offset": [319, 328]}, {"key": "the-claims", "type": "clause", "offset": [401, 411]}, {"key": "to-ensure", "type": "clause", "offset": [419, 428]}, 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"offset": [3917, 3928]}, {"key": "payment-of", "type": "definition", "offset": [4038, 4048]}, {"key": "subject-to", "type": "definition", "offset": [4057, 4067]}, {"key": "right-to", "type": "definition", "offset": [4106, 4114]}, {"key": "action-by-the", "type": "clause", "offset": [4151, 4164]}, {"key": "funds-received", "type": "definition", "offset": [4208, 4222]}, {"key": "any-state", "type": "definition", "offset": [4238, 4247]}], "hash": "9e2a3c2ffb812403600f84b7943bddbc", "id": 9}, {"snippet": "The Contractor shall: 5.\n1.12.3.2.1.1 On the Daily Inbound Demographic Change File provide all third party liability information on the Contractor\u2019s Enrollees;", "size": 2, "samples": [{"hash": "jhDo7JA1cpy", "uri": "/contracts/jhDo7JA1cpy#cost-avoidance", "label": "Contract", "score": 26.1704312115, "published": true}], "snippet_links": [{"key": "the-contractor-shall", "type": "clause", "offset": [0, 20]}, {"key": "the-daily", "type": "clause", "offset": [41, 50]}, {"key": "demographic-change", "type": "clause", "offset": [59, 77]}, {"key": "information-on-the-contractor", "type": "clause", "offset": [117, 146]}], "hash": "10b1ed256e9d3f9bd99e0427aecc7494", "id": 10}], "next_curs": "ClcSUWoVc35sYXdpbnNpZGVyY29udHJhY3RzcjMLEhZDbGF1c2VTbmlwcGV0R3JvdXBfdjU2Ihdjb3N0LWF2b2lkYW5jZSMwMDAwMDAwYQyiAQJlbhgAIAA=", "clause": {"title": "Cost Avoidance", "children": [["exceptions-to-the-cost-avoidance-rule", "Exceptions to the Cost-Avoidance Rule"], ["", ""], ["cost-avoidance-and-recovery", "Cost Avoidance and Recovery"], ["reporting", "Reporting"], ["other-insurance", "Other Insurance"]], "size": 53, "parents": [["coordination-of-benefits", "COORDINATION OF BENEFITS"], ["reporting-requirements", "REPORTING REQUIREMENTS"], ["third-party-liability-and-coordination-of-benefits", "THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS"], ["claims-encounter-processing", "CLAIMS/ENCOUNTER PROCESSING"], ["third-party-liability", "Third Party Liability"]], "id": "cost-avoidance", "related": [["long-term-cost-evaluation", "Long Term Cost Evaluation", "Long Term Cost Evaluation"], ["long-term-cost-evaluation-criterion-4", "Long Term Cost Evaluation Criterion # 4", "Long Term Cost Evaluation Criterion # 4"], ["long-term-cost-evaluation-criterion", "Long Term Cost Evaluation Criterion", "Long Term Cost Evaluation Criterion"], ["salary-sacrifice-arrangements", "SALARY SACRIFICE ARRANGEMENTS", "SALARY SACRIFICE ARRANGEMENTS"], ["management-plan", "Management Plan", "Management Plan"]], "related_snippets": [], "updated": "2025-07-07T12:37:48+00:00", "also_ask": [], "drafting_tip": "", "explanation": "A Cost Avoidance clause is designed to prevent unnecessary or excessive expenses during the execution of a contract. It typically requires parties to take reasonable steps to minimize costs, such as seeking alternative suppliers, optimizing resource use, or avoiding redundant expenditures. By establishing clear expectations for cost management, this clause helps control project budgets and ensures that both parties act in good faith to avoid wasteful spending."}, "json": true, "cursor": ""}}