Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment.
Provider Payment. The Contract must include a provider payment provision that describes the methodology to be used as a basis for payment to the provider. However, the agreement shall not include a rate methodology that provides for an automatic increase in rates. This provision shall be consistent with the Reimbursement Policy required under G.S. 58-3-227(a)(5).
Provider Payment. The contract must include a provider payment provision that describes the methodology to be used as a basis for payment to the provider. However, the agreement shall not include a rate methodology that provides for an automatic increase in rates. Provider agrees to send 837 HIPAA compliant transactions and to receive 835 Remittances or to participate in the PIHP’s web-based billing process. (Attachment F.a.xv.p.319)
Provider Payment. 5.1 Medavie Blue Cross agrees to make payments to the Provider or its Assignee (in cases where the Provider has assigned payment to a third party) for claims submitted during the relevant claim period on a weekly basis, only where the Provider has met all of the following criteria: a) the Provider is an approved Medavie provider, b) the Provider is registered for electronic claims, c) the Provider is registered for direct deposit, c) the Provider accesses the online payment summary (ePayment Summary). Medavie Blue Cross agrees to make payment to the Provider or its Assignee (in cases where the Provider has assigned payment to a third party) where the Provider (or its Assignee) are paid by cheque, together with an online Payment Summary (ePayment Summary), every second week of the amount due for claims received by Medavie Blue Cross from the Provider for the claims submitted during the relevant claim period.
Provider Payment. In accordance with Section 1932(f) of the Social Security Act (42 U.S.C. §1396a-2) the Contractor shall pay all in-and out-of-network providers on a timely basis, consistent with the claims payment procedure described in 42 C.F.R. §§ 447.45, 447.46, 438.60, Section 1902 (a)(37), upon receipt of all clean claims for covered services rendered to covered members who are enrolled with the Contractor. 42 C.F.R. § 447.45 defines timely processing of claims as: • Adjudication (pay or deny) of ninety per cent (90%) of all clean claims within thirty (30) days of the date of receipt. • Adjudication (pay or deny) of ninety-nine per cent (99%) of all clean claims within ninety (90) days of the date of receipt. • Adjudication (pay or deny) all other claims within twelve (12) months of the date of receipt. (See 42 C.F.R. § 447.45 for timeframe exceptions).This requirement shall not apply to network providers who are not paid by the Contractor on a fee-for- service basis and will not override any existing negotiated payment scheduled between the Contractor and its providers. This requirement applies to Virginia FAMIS clean claims. The Contractor shall notify the Department forty-five (45) days in advance of any proposal to modify claims operations and processing that shall include relocation of any claims processing operations. Any expenses incurred by the Department or its contractors to adapt to the Contractor’s claims processing operational changes (including but not limited to costs for site visits) shall be borne by the Contractor. The Contractor must make available to providers an electronic means of submitting claims. In addition, the Contractor shall make every effort to assure at least sixty (60%) percent of claims received from providers are submitted electronically. The Contractor must pay interest charges on claims in compliance with requirements set forth in § 38.2-4306.1 of the Code of Virginia. Specifically interest upon the claim proceeds paid to the subscriber, claimant, or assignee entitled thereto shall be computed daily at the legal rate of interest from the date of thirty calendar days from the Contractor’s receipt of “proof of loss” to the date of claim payment. "Proof of loss" means the date on which the Contractor has received all necessary documentation reasonably required by the Contractor to make a determination of benefit coverage. This requirement does not apply to claims for which payment has been or will be made directly to health care prov...
Provider Payment. 5.1 Medavie Blue Cross agrees to make payment to the Provider or its Assignee (in cases where the Provider has assigned payment to a third party) every second week of the amount due for claims received by Medavie Blue Cross from the Provider together with a payment summary for the claims submitted during the relevant claim period.
Provider Payment
