Common use of PROGRAM GOALS AND OBJECTIVES Clause in Contracts

PROGRAM GOALS AND OBJECTIVES. In order to process payment for medical claims, the Department is soliciting the services from a Third Party Administrator (TPA) to review, adjudicate and process payment in an accurate and efficient manner. Each division will have their own separate program for adjudicating and paying claims. This includes payment, reimbursement rates, providers, and plan dates. With respect to services provided to County Corrections, Medical Clinic and ▇▇▇▇ ▇▇▇▇▇, facility bills will be presented to the TPA in a standard UB-04 format. The bills shall be valued by the TPA at the Orange County contracted rate for each facility. Professional services shall be presented in a standard Health Care Financing Administration CMS/HCFA 1500 format and adjudicated based on applicable provider fee schedule, unless their TPA receives notification from the County to adjudicate the claim at a different rate. Any change to a fee schedule requires a thirty (30) day notification to the TPA prior to the effective date of the change. The county will advance $400,000 for each program to pay claims. The funds shall be kept in a separate bank account and reconciliation shall be completed and sent to each program on a weekly basis. The reconciliation report shall include the number of the check used to pay the claim, claim ID number (specific to the TPA), patient ID number (assigned by each program), last name, first name, provider name, billed rate, paid rate, and date of service. The report shall accompany an invoice from the vendor for reconciliation services. There shall be four invoices and reconciliation reports sent out weekly: ▇▇▇▇ ▇▇▇▇▇ medical claims, ▇▇▇▇ ▇▇▇▇▇ dental claims, Medical Clinic and Corrections Health claims. The county will replenish the deposit for the amount paid in claims by the TPA. Corrections Health Plan Year: 10/1-9/30 Medical Clinic Year: 10/01 – 9/30 ▇▇▇▇ ▇▇▇▇▇ Plan Year: 3/1-2/28 Corrections Health Providers: Approximately 300 providers Medical Clinic Providers: Approximately 500 providers ▇▇▇▇ ▇▇▇▇▇ Providers: Approximately 250 providers The service date on the claim form determines which year plan a claim hits. ▇▇▇▇ ▇▇▇▇▇ Claims Adjudicated: 7,000 claims per year Medical Clinic Year: 25,000 claims per year Corrections Health Adjudicated: 8,000 claims per year The adjudication date determines which year plan the adjudication fee hits.