Governmental Health Care Programs Clause Samples

Governmental Health Care Programs. If you are enrolled in a group with fewer than twenty (20) employees, your benefits will be reduced if you are enrolled for coverage under any federal, state (except Medicaid) or local government health care program. Under federal law, for groups with twenty (20) or more employees, all active employees (regardless of age) can remain on the group’s health plan and receive group benefits as primary coverage. Also, spouses (regardless of age) of active employees can remain on the group’s health plan and receive group benefits as primary coverage. All health care providers must submit Clean Claims. Alliant reserves the right to request and review medical records in order to allow for the determination of benefits according to the Contract. In accordance with Alliant’s policies and procedures, no benefits will be payable by Alliant if the health care provider does not submit a Clean Claim, obtain required Prior Authorization approvals, and submit upon request complete/legible itemization and complete/legible medical records. At Alliant’s discretion, all claims are subject to audit by Alliant or by an independent bill review firm and/or claim auditor. Alliant’s medical bill audit may be performed with or without records, and the review is not subject to waiver by any third-party agreement including, but not limited to, any Provider Network Agreement(s), unless specifically prohibited, or other re-pricing arrangements, or the guidelines of any health care provider (e.g., physician, hospital or other facility). Alliant will evaluate Clean Claims to ensure that the charges are correct and proper, billed using the most accurate and appropriate Current Procedural Terminology (CPT), International Classification of Diagnosis (ICD), Healthcare Common Procedure Coding System (HCPCS) and Revenue codes, and if applicable, documented in the medical records. All Contract/claim adjudication determinations will be made using Alliant’s Policies and Procedures that are based on the coding and billing guidelines of the American Medical Association, the CMS’/Federal Government’s guidelines for proper coding and billing, including, but not limited to, the CMS Provider Billing and/or Reimbursement Guidelines, the National Correct Coding Initiative (NCCI) guidelines, the CMS Physician Fee Schedule (PFS) Relative Value File, and other Federal/clinical acceptance or coverage guidelines published by the Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), an...

Governmental Health Care Programs. To the Company’s Knowledge: (a) Company does not employ or contract with any person who has been excluded from participation in a federal health care program (as defined in 42 U.S.C. Section 1320a-7b(f)). (b) Company is qualified for participation in the Medicare and Medicaid governmental health care programs, has a current and valid provider contract with such programs, and is, and has been, in compliance with the conditions of participation in such programs. Except as has been separately disclosed in writing to Purchaser, no Seller nor Company has received notice of any pending or threatened investigation or inquiry (other than routine surveys and audits that have not resulted in an investigation or inquiry) from any Governmental Authority, fiscal intermediary, carrier or similar entity that enforces or administers the statutory or regulatory provisions in respect of any governmental health care program. (c) There are no outstanding or threatened reviews, claims, judgments, orders, writs, injunctions or decrees by or before any Governmental Authority (including without limitation CMS), intermediary or carrier in respect of any governmental health care program against Sellers or Company that could result in liability of Sellers or Company (whether or not covered by insurance), that could affect or delay any of the Seller’s, the any pharmacist's or Company's performance of this Agreement or that could have a Material Adverse Effect upon Purchaser or Company. (d) Schedule 3.27(d) sets forth a complete and correct list of each Governmental Permit owned, held or possessed by Company as of the date hereof that is necessary to operate the Business, together with: (i) Medicare and Medicaid provider numbers; (ii) copies of all bio hazardous waste permits; (iii) copies of all registrations for diagnostic imaging equipment utilized at the Company’s facilities; (iv) copies of occupational licenses for each of the Company’s facilities. Company has fulfilled and performed in all respects its obligations under each of the Governmental Permits that it owns, holds or possesses, and no written notice of cancellation, default or dispute concerning any Governmental Permit, has been received by Company or any Seller.

Governmental Health Care Programs. ‌ When Your Coverage Terminates‌ When Will My Alliant Membership End?‌