DMC Claims and Reports Sample Clauses
The "DMC Claims and Reports" clause outlines the procedures and requirements for submitting and handling claims and reports related to the Designated Managing Contractor (DMC) within a contract. Typically, this clause specifies the types of claims that must be reported, the format and timing for submitting such claims, and the documentation required to support them. For example, it may require the DMC to provide regular progress reports or to notify the other party promptly of any issues that could give rise to a claim. The core function of this clause is to ensure transparency and accountability in the management of claims, thereby facilitating timely resolution of disputes and maintaining clear communication between parties.
DMC Claims and Reports i. Contractor or providers that ▇▇▇▇ DHCS or the Contractor for DMC- ODS services shall submit claims in accordance with Department of Health Care Service’s DMC Provider Billing Manual.
ii. Contractor and subcontractors that provide DMC services shall be responsible for verifying the Medi-Cal eligibility of each beneficiary for each month of service prior to billing for DMC services to that beneficiary for that month. Medi-Cal eligibility verification should be performed prior to rendering service, in accordance with and as described in the DHCS DMC Provider Billing Manual. Options for verifying the eligibility of a Medi-Cal beneficiary are described in the Department of Health Care Services DMC Provider Billing Manual.
iii. Claims for DMC reimbursement shall include DMC-ODS services covered under the Special Terms and Conditions of this Agreement, and any State Plan services covered under Title 22, Section 51341.1(c-d) and administrative charges that are allowed under W&I Code, Sections 14132.44 and 14132.47.
a. Contractor shall submit to DHCS the “Certified Expenditure” form reflecting either: 1) the approved amount of the 837P claim file, after the claims have been adjudicated; or 2) the claimed amount identified on the 837P claim file, which could account for both approved and denied claims. Contractor shall submit to DHCS the Drug Medi-Cal Certification Form DHCS 100224A (Document 4D) for each 837P transaction approved for reimbursement of the federal Medicaid funds.
b. DMC service claims shall be submitted electronically in a Health Insurance Portability and Accountability Act (HIPAA) compliant format (837P). All adjudicated claim information shall be retrieved by the Contractor via an 835 HIPAA compliant format (Health Care Claim Payment/Advice).
iv. The following forms shall be prepared as needed and retained by the provider for review by state staff:
a. Good Cause Certification (6065A), Document 2L(a)
b. Good Cause Certification (6065B), Document 2L(b)
c. In the absence of good cause documented on the Good Cause Certification (6065A or 6065B) form, claims that are not submitted within 30 days of the end of the month of service shall be denied. The existence of good cause shall be determined by DHCS in accordance with Title 22, Sections 51008 and 51008.5.