Common use of Paid Claims Clause in Contracts

Paid Claims. Paid Claims shall be included in Benefit Expense. The Department shall use Encounter Data claims for all dates of service during the Coverage Year and accepted by the Department within six (6) months after the end of the Coverage Year. If the Parties are unable to resolve Encounter Data systems issues prior to calculation of the MLR, the Parties will agree on an alternative method of calculating paid claims expense. Encounter Data claims covered by sub-capitation contracts shall be priced at Contractor’s Fee-For-Service rate for Covered Services. If Contractor does not have a published fee schedule for a Covered Service, the price on the sub- capitated service may not exceed one hundred ten percent (110%) of the Department’s Medicaid rate.