Common use of Eligible Claims Clause in Contracts

Eligible Claims. A claim must meet all of the following criteria in order to qualify as an Eligible Claim under this Settlement Agreement: a. The claim is for Medicare home health benefits under Parts A or B, not Part C; b. The claim is for services provided to a Medicare beneficiary located in Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, or Vermont at the time the claim received the initial determination from the MAC; c. The claim was denied on the basis that the beneficiary was not homebound; d. The claim was denied on or between January 1, 2010 through August 3, 2015; e. The claim is for services provided to a Medicare beneficiary who received a favorable final appellate decision that he or she was homebound at any of the four levels of Medicare administrative appeal prior to the denial date for that claim; f. The appeal of that claim denial: (a) was pending at any of the four levels of Medicare appeal as of March 5, 2015; or (b) was within the time period for appeal at any of the four levels of Medicare administrative appeal as of March 5, 2015, and an appeal of the initial denial was timely filed; g. Claims other than of the Named Plaintiffs that are currently the subject of any lawsuit pending in an Article III United States Court, or have been the subject of a final, non-appealable judgment by such courts, are not eligible for re-review; h. The appeal of that claim denial is pursued by a beneficiary on his or her own behalf, or through a representative other than a provider, supplier, or Medicaid State Agency. Appeals of claim denials pursued by providers or suppliers or Medicaid State agencies are excluded. No provider or supplier or Medicaid State Agency is permitted to receive re-review on behalf of or by assignment from a class member; i. Claim for services must not have been covered or paid for by Medicare or by any third-party payor or insurer except in the case of an individual Medicare beneficiary whose services were paid in full or part by Medicaid; and j. For cases not currently pending in the Medicare administrative claims appeals process, there must not have been a determination by the last Medicare adjudicator to review the claim (MAC, Qualified Independent Contractor (QIC), Administrative Law Judge (ALJ), or Medicare Appeals Council (Appeals Council)) that there was a separate and independent basis for denial of the claim other than failure to meet the homebound requirements of the Medicare home health benefit.