Common use of Governmental Health Care Programs Clause in Contracts

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), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that:

Governmental Health Care Programs. If you You are enrolled in a group with fewer than twenty (20) employees, your Your benefits will be reduced if you 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), and/or the Federal National Library of Medicine-National Institute of Health. As a result of any claim audit/review, Alliant will not provide benefits for services and supplies that: