Payments to Managed Care Organization Sample Clauses

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July 1, 2017, through June 30, 2018 (State Fiscal Year 2018). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, paymen...
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