Notice to Provider. Resident must communicate with the Provider in writing via the Provider’s University e-mail address. Provider may also provide Resident the opportunity to communicate requests via electronic forms or documents.
Notice to Provider. If BCBSM suspends or terminates this Agreement, BCBSM must give affected Provider individual written notice of the following: (i) the reasons for the action, including, if relevant, the standards and profiling data used to evaluate Providers and the numbers of Providers needed by BCSBM; and (ii) affected Provider’s right to appeal the action and the process and timing for requesting a hearing.
Notice to Provider. In the event Provider’s participation in a Plan Benefit Program is denied, suspended, or terminated, PMC or Payer shall provide Provider the notice required under 42 C.F.R. 422.204 (c)(1). EXHIBIT C REQUIREMENTS OF A CLEAN CLAIM Description HCFA 1500 HCFA 1500 field number The following data elements must be complete, legible, and accurate: Patient’s ID Number 1a Patient’s Name 2 Patient’s Date of Birth and gender 3 Subscriber’s Name 4 Patient’s Address (street or P.O. Box, city, zip) 5 Patient’s relationship to Subscriber 6 Subscriber’s address (street or P.O. Box, city, zip) 7 Other insured’s or enrollee’s name if patient is covered by more than one health benefit plan 9 Other insured’s or enrollee’s policy/group number 9a Other insured’s or enrollee’s date of birth 9b Other insured’s or enrollee’s plan name (employer, school, etc.) 9c Other insured’s or enrollee’s health plan name 9d Whether patient’s condition is related to employment, auto accident, or other accident 10a-c Subscriber’s policy number 11 Subscriber’s birth date and gender 11a Subscriber’s plan name (employer, school, etc.) 11b Health Plan name 11c Disclosure of any other health benefit plans; if respond “yes” to 11d, then complete 9 through 9d; if respond “no” to 1 Id, then data elements 9 through 9d are not essential to the claim 11d Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider 12 Subscriber’s or authorized person’s signature or notation that the signature is on file with the physician or provider 13 Date of current illness, injury, or pregnancy 14 First date of previous same or similar illness 15 Referring physician’s name 17 Referring physician’s UPIN number, if applicable 17a Valid diagnosis code(s) to the fifth digit when applicable 21 Prior authorization number, if services require prior authorization 23 Date(s) of service 00x Xxxxx xxxxx of service codes 24b Valid type of service code 24c Valid procedure/modifier code 24d Diagnosis code pointer by specific service 24e Charge for each listed service 24f Number of days or units 24g Reserved for local use (performing provider number), required if group practice 24k Description HCFA 1500 HCFA 1500 field number Physician’s or provider’s federal tax ID number 25 Whether assignment was accepted (applicable when assignment under Medicare is accepted) 27 Total charge 28 Amount paid is required if (1) an amount has been paid to the physician or provider submitting the c...
Notice to Provider. Please note: For hospitals, the PPA is used for inpatient care only. Services provided in the Emergency department of a hospital do not require a PPA but should be billed directly.
Notice to Provider. Borrower shall notify Provider immediately if Provider’s Equipment is involved in any accident during the share period. Borrower shall promptly submit to Provider a written report of any accident that occurs in connection with this Agreement, in a form acceptable to Provider, and shall cooperate with any requests by Provider related to the accident. Borrower’s report to provider must include, at a minimum, the following information: (1) name and address of any person injured or deceased, or the owner of any property that suffered damage as the result of the accident; (2) name and address of Borrower’s employee(s) involved in the accident;
Notice to Provider. All notices from CITY to PROVIDER pursuant to or concerning this Agreement, shall be delivered to PROVIDER's headquarter offices , and such other office as PROVIDER may designate by written notice to CITY.
Notice to Provider. CHESS may notify Provider be email, postal mail, postings within the Solutions, or other legally acceptable means.
Notice to Provider. Failure to include all of the information required in SECTION 3.01 with each invoice may resultin a significant delay in processing payment for the invoice. REMAINDER OF XXXX INTENTIONALLY LEFT BLANK II. PROVIDER’S WARRANTY, AFFIRMATIONS, AND ASSURANCES
Notice to Provider. Please note: For hospitals, the PPA is used for inpatient care only. Services provided in the Emergency Department of a hospital do not require a PPA but should be billed directly. Please see ED Billing link here: xxxxx://xx.xxxxxxxxxxxxxxx.xxx//for-providers/emergency-department-claims-from-out- of-network-hospitals Please note: PPAs are also reserved for crisis or urgent care services and should not be utilized for services that could be covered under a Client Specific Agreement (CSA) which should be established prior to service provision. For further information regarding CSAs, please reach out to Xxxx Xxxxxx at xxxxx@xxxxxxxxxxxxxxx.xxx or contact Sandhills Center via the Provider Help Desk at 0-000-000-0000. The only exception to this standard is in the event that a member’s Medicaid has transitioned to Sandhills Center from another LME/MCO and the provider has outstanding billing as result of non-urgent/non-crisis services being provided during the transition period. A PPA will be considered on a case-by-case basis. Please send the completed Provider Payment Agreement with the additional required documentation to: xxxxxxxxxxxxxxxxxxxxxxxx@xxxxxxxxxxxxxxx.xxx or fax Network, (000) 000-0000 or mail to Sandhills Center, Attn: Contracts Xxxx, 0000 Xxxxxx Xxxxxxx Way, Greensboro, NC 27410. The following documents must be included in the packet in order to process your payment request.
