Common use of Submission of Claims Clause in Contracts

Submission of Claims. Either You or the Provider of service must claims benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one-hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable. How to file In-Network Medical Claims Xxxxx follows all Department of Managed Health Care regulations when it comes to the payment of claims. Please submit Your claims as soon as possible in order to expedite payments. Any benefits determined to be due under this Agreement shall be paid within thirty (30) working days after We receive a complete written proof of loss and determination that benefits arepayable. When using an In-Network Provider they will bill Oscar directly for services rendered to You. In order for the Provider to submit a claim on Your behalf, You must give the Provider information necessary for the claim to be filed, such as Your Oscar ID card. Contracted providers must submit claims within one hundred eighty (180) calendar days following the dates of service, unless otherwise mandated by law or in the provider contract. A claim received after the one hundred eighty (180) days billing time limit may be subject to a denial. How to file Out-of-Network Emergency and Urgent Care claims: After You get Covered Services for Out-of-Network Emergency or Urgent Care, We must receive written notice of Your claim within one-hundred eighty (180) days, or as soon thereafter as reasonably possible. Either the Subscriber or Provider of service must claim benefits by sending Us properly completed claim forms itemizing the services or supplies received and the charges. These claim forms must be received by Us within one- hundred eighty (180) calendar days from the date the services or supplies are received. We will not be liable for benefits if We do not receive completed claim forms within this time period. General claim filing guidelines: Claim forms must be used; canceled checks or receipts are not acceptable. Claim forms are available by accessing Our web site at xxx.xxxxxxx.xxx by calling the telephone number on the back of Your Identification Card or by writing to Us at the address in the next sentence. Prior to submitting Your member claim form and itemized bill, You should make copies of the documents for Your own records and attach the original bills to the completed member claim form. The bills and the member claim form should be mailed to: Oscar Health Plan of California Attn: Claims 0000 Xxxxxx Xxxx Blvd. PO Box 1279 Culver City, CA 90232 Out-of-Network providers must submit claims within one-hundred eighty (180) calendar days following the dates of service unless otherwise mandated by law. A claim received after the one-hundred eighty (180) days billing time limit is subject to denial. When You receive health care outside of the United States, You will need to submit an itemized bill and medical records for services rendered. The itemized bill and medical records must be translated into English and include the billed charges. Note: You are responsible, at Your own expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. Other Charges Copayments and Coinsurance are outlined in the SUMMARY OF BENEFITS. Your Copayment and Coinsurance may be a fixed dollar amount per day, per visit, and/or it may be a percentage of the Negotiated Fee Rate. Important: You are responsible for confirming that the Provider You are seeing or have been referred to see is an In-Network Provider under Your Plan. Unless an exception (listed in the HOW YOUR COVERAGE WORKS section) applies, any claims incurred with a Provider who is not a part of Your Plan’s In-Network Providers will not be covered. Xxxxx can help You find an In-Network Provider specific to Your Plan. Call customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. These amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by You at the time services are performed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services as stated in the sections below. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected by the Provider at the time services are performed, the Provider may choose to bill You for these services after they have submitted the claim to Us. Cost sharing for services with Copayments is the lesser of the Copayment amount or Negotiated Fee Rate. Described below are Your Coinsurance and Out of Pocket Maximums.

Submission of Claims. Either You or the Provider of service must claims benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from the date of services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar within one-hundred eighty (180) days from the date of services. Xxxxx will not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable. How to file In-Network Medical Claims Xxxxx follows all Department of Managed Health Care regulations when it comes to the payment of claims. Please submit Your claims as soon as possible in order to expedite payments. Any benefits determined to be due under this Agreement shall be paid within thirty (30) working days after We receive a complete written proof of loss and determination that benefits arepayableare payable. When using an In-Network Provider they will bill Oscar directly for services rendered to You. In order for the Provider to submit a claim on Your behalf, You must give the Provider information necessary for the claim to be filed, such as Your Oscar ID card. Contracted providers must submit claims within one hundred eighty (180) calendar days following the dates of service, unless otherwise mandated by law or in the provider contract. A claim received after the one hundred eighty (180) days billing time limit may be subject to a denial. How to file Out-of-Network Emergency and Urgent Care claims: After You get Covered Services for Out-of-Network Emergency or Urgent Care, We must receive written notice of Your claim within one-hundred eighty (180) days, or as soon thereafter as reasonably possible. Either the Subscriber or Provider of service must claim benefits by sending Us properly completed claim forms itemizing the services or supplies received and the charges. These claim forms must be received by Us within one- hundred eighty (180) calendar days from the date the services or supplies are received. We will not be liable for benefits if We do not receive completed claim forms within this time period. General claim filing guidelines: Claim forms must be used; canceled checks or receipts are not acceptable. Claim forms are available by accessing Our web site at xxx.xxxxxxx.xxx by calling the telephone number on the back of Your Identification Card or by writing to Us at the address in the next sentence. Prior to submitting Your member claim form and itemized bill, You should make copies of the documents for Your own records and attach the original bills to the completed member claim form. The bills and the member claim form should be mailed to: Oscar Health Plan of California Attn: Claims 0000 Xxxxxx Xxxx Blvd. PO Box 1279 Culver City, CA 90232 Out-of-Network providers must submit claims within one-hundred eighty (180) calendar days following the dates of service unless otherwise mandated by law. A claim received after the one-hundred eighty (180) days billing time limit is subject to denial. When You receive health care outside of the United States, You will need to submit an itemized bill and medical records for services rendered. The itemized bill and medical records must be translated into English and include the billed charges. Note: You are responsible, at Your own expense, for obtaining an English language translation of foreign country Provider claims and medicalrecordsmedical records. Other Charges Copayments and Coinsurance are outlined in the SUMMARY OF BENEFITS. Your Copayment and Coinsurance may be a fixed dollar amount per day, per visit, and/or it may be a percentage of the Negotiated Fee Rate. Important: You are responsible for confirming that the Provider You are seeing or have been referred to see is an In-Network Provider under Your Plan. Unless an exception (listed in the HOW YOUR COVERAGE WORKS section) applies, any claims incurred with a Provider who is not a part of Your Plan’s In-Network Providers will not be covered. Xxxxx can help You find an In-Network Provider specific to Your Plan. Call customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. These amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by You at the time services are performed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services as stated in the sections below. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected by the Provider at the time services are performed, the Provider may choose to bill You for these services after they have submitted the claim to Us. Cost sharing for services with Copayments is the lesser of the Copayment amount or Negotiated Fee Rate. Described below are Your Coinsurance and Out of Pocket Maximums.

Submission of Claims. Either You or the Provider of service must claims benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms Claims must be received by Xxxxx within one hundred eighty (180) submitted to the LME/PIHP electronically either through HIPAA Compliant 5010 EDI Transaction Sets: 837P – Professional claims, 837I – Institutional claims, or through direct data entry in the LME/PIHP’s secure web based claims system. The LIP will receive from the LME/PIHP a HIPAA Compliant 5010 EDI Transaction Sets: 835 – Remittance advice and/or a Remittance Advice can be generated directly from the secure web based claims system. LIP’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. Claims for services must be submitted within ninety (90) days of the date of service except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or supplies discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. and f. below. LME/PIHP is not responsible for processing or payment of claims that are receivedsubmitted more than ninety (90) days after the date of service or discharge (whichever is later) except in the instances denominated in subparagraph8.e. and f. below. The date of receipt is the date the LME/PIHP receives the claim, as indicated on the electronic data records. If LIP delays claims due to the claim is subrogation of benefits or the determination of eligibility for an Out-of-Network Emergency Center benefits for the Enrollee, LIP shall submit claims to the LME/PIHP within ninety (90) days of receipt of notice by the LIP of the Enrollee’s eligibility for Medicaid. If LIP delays submission of the claims due to the coordination of benefits, subrogation of benefits or Urgent Care Centerthe determination of eligibility for benefits for the Enrollee , these claim forms must be received by Oscar LIP shall submit such claims within one-hundred eighty ninety (18090) days from the notice of determination of coverage or payment by the third party up to 180 days from date of servicesservice. Xxxxx will If a claim is denied for reasons other than those stated above in subparagraph 8.e. and f., and the LIP wishes to resubmit the denied claim with additional information, XXX must resubmit the claim within ninety (90) days after XXX’s receipt of the denial. If the LIP needs more than ninety (90) days to resubmit a denied claim, LIP must request and receive an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable. How to file In-Network Medical Claims Xxxxx follows all Department of Managed Health Care regulations when it comes to the payment of claims. Please submit Your claims as soon as possible in order to expedite payments. Any benefits determined to be due under this Agreement unreasonably withheld. All claims shall be paid within thirty (30) working days after We receive a complete written proof of loss and determination that benefits arepayable. When using an In-Network Provider they will bill Oscar directly for services rendered to You. In order for the Provider to submit a claim on Your behalf, You must give the Provider information necessary for the claim to be filed, such adjudicated as Your Oscar ID card. Contracted providers must submit claims within one hundred eighty (180) calendar days following the dates of service, unless otherwise mandated by law or in the provider contract. A claim received after the one hundred eighty (180) days billing time limit may be subject to a denial. How to file Out-of-Network Emergency and Urgent Care claims: After You get Covered Services for Out-of-Network Emergency or Urgent Care, We must receive written notice of Your claim within one-hundred eighty (180) days, or as soon thereafter as reasonably possible. Either the Subscriber or Provider of service must claim benefits by sending Us properly completed claim forms itemizing the services or supplies received and the charges. These claim forms must be received by Us within one- hundred eighty (180) calendar days from the date the services or supplies are received. We will not be liable for benefits if We do not receive completed claim forms within this time period. General claim filing guidelines: Claim forms must be used; canceled checks or receipts are not acceptable. Claim forms are available by accessing Our web site at xxx.xxxxxxx.xxx by calling the telephone number on the back of Your Identification Card or by writing to Us at the address in the next sentence. Prior to submitting Your member claim form and itemized bill, You should make copies of the documents for Your own records and attach the original bills to the completed member claim form. The bills and the member claim form should be mailed to: Oscar Health Plan of California Attn: Claims 0000 Xxxxxx Xxxx Blvd. PO Box 1279 Culver City, CA 90232 Out-of-Network providers must submit claims within one-hundred eighty (180) calendar days following the dates of service unless otherwise mandated by law. A claim received after the one-hundred eighty (180) days billing time limit is subject to denial. When You receive health care outside of the United States, You will need to submit an itemized bill and medical records for services rendered. The itemized bill and medical records must be translated into English and include the billed charges. Note: You are responsible, at Your own expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. Other Charges Copayments and Coinsurance are outlined in the SUMMARY OF BENEFITSProvider Operations Manual and Chapter 108C of the North Carolina General Statutes. Your Copayment and Coinsurance Billing Diagnosis submitted on claims must be consistent with the service provided. If a specific service (as denominated by specific identifying codes such as CPT or HCPCS) is rendered multiple times in a single day to the same Enrollee, the specific service may be a fixed dollar amount per day, per visit, and/or it may be a percentage billed as the aggregate of the Negotiated Fee Rate. Important: You are responsible for confirming that the Provider You are seeing or have been referred to see is an In-Network Provider under Your Plan. Unless an exception (listed in the HOW YOUR COVERAGE WORKS section) applies, any claims incurred with a Provider who is not a part of Your Plan’s In-Network Providers will not be covered. Xxxxx can help You find an In-Network Provider specific to Your Plan. Call customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. These amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by You at the time services are performed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services units delivered rather than as stated in the sections below. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected by the Provider at the time services are performed, the Provider may choose to bill You for these services after they have submitted the claim to Us. Cost sharing for services with Copayments is the lesser of the Copayment amount or Negotiated Fee Rate. Described below are Your Coinsurance and Out of Pocket Maximumsseparate line items.

Submission of Claims. Either You or the Provider of service must claims benefits by sending Xxxxx properly completed claims forms itemizing the services or supplies received and the charges. These claim forms Claims must be received by Xxxxx within one hundred eighty (180) submitted to the LME/PIHP electronically either through HIPAA Compliant 5010 EDI Transaction Sets: 837P – Professional claims, 837I – Institutional claims, or through direct data entry in the LME/PIHP’s secure web based claims system. The LIP will receive from the LME/PIHP a HIPAA Compliant 5010 EDI Transaction Sets: 835 – Remittance advice and/or a Remittance Advice can be generated directly from the secure web based claims system. LIP’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. Claims for services must be submitted within ninety (90) days of the date of service except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or supplies discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. and f. below. LME/PIHP is not responsible for processing or payment of claims that are receivedsubmitted more than ninety (90) days after the date of service or discharge (whichever is later) except in the instances denominated in subparagraph8.e. and f. below. The date of receipt is the date the LME/PIHP receives the claim, as indicated on the electronic data records. If LIP delays claims due to the claim is subrogation of benefits or the determination of eligibility for an Out-of-Network Emergency Center benefits for the Enrollee, LIP shall submit claims to the LME/PIHP within ninety (90) days of receipt of notice by the LIP of the Enrollee’s eligibility for Medicaid. If LIP delays submission of the claims due to the coordination of benefits, subrogation of benefits or Urgent Care Centerthe determination of eligibility for benefits for the Enrollee , these claim forms must be received by Oscar LIP shall submit such claims within one-hundred eighty ninety (18090) days from the notice of determination of coverage or payment by the third party up to 180 days from date of servicesservice. Xxxxx will If a claim is denied for reasons other than those stated above in subparagraph 8.e. and f., and the LIP wishes to resubmit the denied claim with additional information, LIP must resubmit the claim within ninety (90) days after LIP’s receipt of the denial. If the LIP needs more than ninety (90) days to resubmit a denied claim, LIP must request and receive an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not be liable for benefits if a completed claim form is not furnished to Oscar within this time period, except in the absence of legal capacity. Claims forms must be used, canceled checks or receipts are not acceptable. How to file In-Network Medical Claims Xxxxx follows all Department of Managed Health Care regulations when it comes to the payment of claims. Please submit Your claims as soon as possible in order to expedite payments. Any benefits determined to be due under this Agreement unreasonably withheld. All claims shall be paid within thirty (30) working days after We receive a complete written proof of loss and determination that benefits arepayable. When using an In-Network Provider they will bill Oscar directly for services rendered to You. In order for the Provider to submit a claim on Your behalf, You must give the Provider information necessary for the claim to be filed, such adjudicated as Your Oscar ID card. Contracted providers must submit claims within one hundred eighty (180) calendar days following the dates of service, unless otherwise mandated by law or in the provider contract. A claim received after the one hundred eighty (180) days billing time limit may be subject to a denial. How to file Out-of-Network Emergency and Urgent Care claims: After You get Covered Services for Out-of-Network Emergency or Urgent Care, We must receive written notice of Your claim within one-hundred eighty (180) days, or as soon thereafter as reasonably possible. Either the Subscriber or Provider of service must claim benefits by sending Us properly completed claim forms itemizing the services or supplies received and the charges. These claim forms must be received by Us within one- hundred eighty (180) calendar days from the date the services or supplies are received. We will not be liable for benefits if We do not receive completed claim forms within this time period. General claim filing guidelines: Claim forms must be used; canceled checks or receipts are not acceptable. Claim forms are available by accessing Our web site at xxx.xxxxxxx.xxx by calling the telephone number on the back of Your Identification Card or by writing to Us at the address in the next sentence. Prior to submitting Your member claim form and itemized bill, You should make copies of the documents for Your own records and attach the original bills to the completed member claim form. The bills and the member claim form should be mailed to: Oscar Health Plan of California Attn: Claims 0000 Xxxxxx Xxxx Blvd. PO Box 1279 Culver City, CA 90232 Out-of-Network providers must submit claims within one-hundred eighty (180) calendar days following the dates of service unless otherwise mandated by law. A claim received after the one-hundred eighty (180) days billing time limit is subject to denial. When You receive health care outside of the United States, You will need to submit an itemized bill and medical records for services rendered. The itemized bill and medical records must be translated into English and include the billed charges. Note: You are responsible, at Your own expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. Other Charges Copayments and Coinsurance are outlined in the SUMMARY OF BENEFITSProvider Operations Manual and Chapter 108C of the North Carolina General Statutes. Your Copayment and Coinsurance Billing Diagnosis submitted on claims must be consistent with the service provided. If a specific service (as denominated by specific identifying codes such as CPT or HCPCS) is rendered multiple times in a single day to the same Enrollee, the specific service may be a fixed dollar amount per day, per visit, and/or it may be a percentage billed as the aggregate of the Negotiated Fee Rate. Important: You are responsible for confirming that the Provider You are seeing or have been referred to see is an In-Network Provider under Your Plan. Unless an exception (listed in the HOW YOUR COVERAGE WORKS section) applies, any claims incurred with a Provider who is not a part of Your Plan’s In-Network Providers will not be covered. Xxxxx can help You find an In-Network Provider specific to Your Plan. Call customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. These amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by You at the time services are performed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment for services You receive, except for certain services units delivered rather than as stated in the sections below. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected by the Provider at the time services are performed, the Provider may choose to bill You for these services after they have submitted the claim to Us. Cost sharing for services with Copayments is the lesser of the Copayment amount or Negotiated Fee Rate. Described below are Your Coinsurance and Out of Pocket Maximumsseparate line items.

Submission of Claims. Either You Claims must be submitted electronically either through HIPAA Compliant Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, 837P – Professional claims, 837I – Institutional claims, or the Provider of service must LME/PIHP’s secure web based billing system. CONTRACTOR’s claims benefits by sending Xxxxx properly completed claims forms itemizing shall be compliant with the services or supplies received and the charges. These claim forms must be received by Xxxxx within one hundred eighty (180) from National Correct Coding Initiative effective at the date of service. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. Claims for services or supplies are received. If the claim is for an Out-of-Network Emergency Center or Urgent Care Center, these claim forms must be received by Oscar submitted within one-hundred eighty ninety (18090) days from of the date of services. Xxxxx will not be liable for benefits if a completed claim form service or discharge (whichever is not furnished to Oscar within this time periodlater), except in the absence instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of legal capacitythe date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. Claims forms must be usedbelow. LME/PIHP is not responsible for processing or payment of claims that are submitted more than ninety (90) days after the date of service or discharge (whichever is later) except in the instances denominated in subparagraph 8.e. below. The date of receipt is the date the LME/PIHP receives the claim, canceled checks or receipts are not acceptableas indicated on the electronic data records. How to file In-Network Medical Claims Xxxxx follows all Department of Managed Health Care regulations when it comes CONTRACTOR may submit claims subsequent to the ninety (90) day limit in instances where the Enrollee has been retroactively enrolled in the Medicaid program or in the LME/PIHP program, or where the Enrollee has primary insurance which has not yet paid or denied its claim. In such instances, CONTRACTOR may xxxx the LME/PIHP within ninety (90) days of receipt of notice by the CONTRACTOR of the Enrollee’s eligibility for Medicaid and the LME/PIHP, or within 90 days of final action (including payment or denial) by the primary insurance or Medicare the date of claimsservice or discharge (whichever is later). Please If CONTRACTOR delays submission of the claims due to the coordination of benefits, subrogation of benefits or the determination of eligibility for benefits for the Enrollee, CONTRACTOR shall submit Your such claims as soon as possible in order to expedite payments. Any benefits determined to be due under this Agreement shall be paid within thirty (30) working days of the date of the notice of determination of coverage or payment by the third party. If a claim is denied for reasons other than those stated above in subparagraph 7.e., and the CONTRACTOR wishes to resubmit the denied claim with additional information, CONTRACTOR must resubmit the claim within ninety (90) days after We CONTRACTOR’s receipt of the denial. If the CONTRACTOR needs more than ninety (90) days to resubmit a denied claim, CONTRACTOR must request and receive a complete written proof an extension from the LME/PIHP before the expiration of loss and determination that benefits arepayable. When using an In-Network Provider they will bill Oscar directly for services rendered to You. In order for the Provider to submit a claim on Your behalfninety (90) deadline, You must give the Provider information necessary for the claim such extension not to be filed, such unreasonably withheld. All claims shall be adjudicated as Your Oscar ID card. Contracted providers must submit claims within one hundred eighty (180) calendar days following the dates of service, unless otherwise mandated by law or in the provider contract. A claim received after the one hundred eighty (180) days billing time limit may be subject to a denial. How to file Out-of-Network Emergency and Urgent Care claims: After You get Covered Services for Out-of-Network Emergency or Urgent Care, We must receive written notice of Your claim within one-hundred eighty (180) days, or as soon thereafter as reasonably possible. Either the Subscriber or Provider of service must claim benefits by sending Us properly completed claim forms itemizing the services or supplies received and the charges. These claim forms must be received by Us within one- hundred eighty (180) calendar days from the date the services or supplies are received. We will not be liable for benefits if We do not receive completed claim forms within this time period. General claim filing guidelines: Claim forms must be used; canceled checks or receipts are not acceptable. Claim forms are available by accessing Our web site at xxx.xxxxxxx.xxx by calling the telephone number on the back of Your Identification Card or by writing to Us at the address in the next sentence. Prior to submitting Your member claim form and itemized bill, You should make copies of the documents for Your own records and attach the original bills to the completed member claim form. The bills and the member claim form should be mailed to: Oscar Health Plan of California Attn: Claims 0000 Xxxxxx Xxxx Blvd. PO Box 1279 Culver City, CA 90232 Out-of-Network providers must submit claims within one-hundred eighty (180) calendar days following the dates of service unless otherwise mandated by law. A claim received after the one-hundred eighty (180) days billing time limit is subject to denial. When You receive health care outside of the United States, You will need to submit an itemized bill and medical records for services rendered. The itemized bill and medical records must be translated into English and include the billed charges. Note: You are responsible, at Your own expense, for obtaining an English language translation of foreign country Provider claims and medicalrecords. Other Charges Copayments and Coinsurance are outlined in the SUMMARY OF BENEFITSLME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General Statutes. Your Copayment and Coinsurance Billing Diagnosis submitted on claims must be consistent with the service provided. If a specific service (as denominated by specific identifying codes such as CPT or HCPCS) is rendered multiple times in a single day to the same Enrollee, the specific service may be billed as the aggregate of the units delivered rather than as separate line items. The LME/PIHP shall not reimburse CONTRACTOR for “never events.” PAYMENT OF CLAIMS: LME/PIHP shall reimburse CONTRACTOR for approved Clean Claims for covered services requiring prior authorization within thirty days of the date of receipt. Clean claims for emergency services which do not require prior authorization shall be reimbursed within thirty days of the date of receipt. Within eighteen (18) days after the LME/PIHP receives a fixed dollar amount per dayclaim from CONTRACTOR, per visitthe LME/PIHP shall either: (1) approve payment of the claim, (2) deny payment of the claim, or (3) request additional information that is required for making an approval or denial. If the LME/PIHP denies payment of a claim the LME/PIHP shall provide CONTRACTOR the ability to electronically access the specific denial reason. “Claims Status” of a claim shall be available within five to seven (5-7) days of the LME/PIHP receiving the claim. If the LME/PIHP determines that additional information in either original or certified copy form is required for making the approval or denial of the claim, LME/PIHP shall notify the CONTRACTOR within eighteen (18) days after the LME/PIHP received the claim. The CONTRACTOR shall have fifteen (15) days to provide the additional information requested, or the claim shall be denied. Upon LME/PIHP’s receipt of the additional information from the CONTRACTOR, the LME/PIHP shall have an additional eighteen (18) days to process the claim as set forth in Paragraph 2, above. The LME/PIHP is not limited to approving a claim in full or requesting additional information for the entire claim. Rather, as appropriate, the LME/PIHP may approve a claim in part, deny a claim in part, and/or it may be a percentage of the Negotiated Fee Rate. Important: You are responsible request additional information for confirming that the Provider You are seeing or have been referred to see is an In-Network Provider under Your Plan. Unless an exception (listed in the HOW YOUR COVERAGE WORKS section) applies, any claims incurred with a Provider who is not only a part of Your Plan’s In-Network Providers the claim, as long as the LME/PIHP either approves, denies, or requests additional information for each part of the claim within the required eighteen (18) day period. If LME/PIHP fails to pay CONTRACTOR within these parameters, LME/PIHP shall pay to CONTRACTOR interest in the amount of eight percent of the claim amount beginning on the date following the day on which the payment should have been made. The LME/PIHP will not be covered. Xxxxx can help You find an In-Network Provider specific to Your Plan. Call customer service at 1-855-Oscar-55 or visit Us at xxx.xxxxxxx.xxx. These amounts are Your financial responsibility. After Your Deductible is satisfied, Copayments are normally paid by You at the time services are performed. If Your Plan contains a Deductible, You must satisfy the In-Network medical Deductible before We will make payment reimburse CONTRACTOR for services You receiveprovided by staff not meeting licensure, except for certain services as stated in the sections belowcertification, credentialing, or accreditation requirements. Additionally, the medical Deductible is explained in the SUMMARY OF BENEFITS. While Your Coinsurance financial responsibility may also be collected CONTRACTOR understands and agrees that reimbursement rates paid under this Contract are established by the Provider at LME/PIHP. THIRD PARTY REIMBURSEMENT: CONTRACTOR will comply with N.C.G.S. §122C-146, which requires the LME/PIHP to make every reasonable effort to collect payments from third party payors. Each time an Enrollee receives services CONTRACTOR shall determine if the Enrollee has third party coverage that covers the service provided. CONTRACTOR is required to xxxx all applicable third party payors prior to billing the LME/PIHP. Medicaid benefits payable through the LME/PIHP are performedsecondary to benefits payable by a primary payer, including Medicare, even if the Provider may choose primary payer states that its benefits are secondary to bill You for these services after they have submitted Medicaid benefits or otherwise limits its payments to Medicaid enrollees. The LME/PIHP makes secondary payments to supplement the claim to Us. Cost sharing for services with Copayments primary payment if the primary payment is less than the lesser of the Copayment usual and customary charges for the service or the rate established by the LME/PIHP. The LME/PIHP does not make a secondary payment if the CONTRACTOR is either obligated to accept, or voluntarily accepts, as full payment, a primary payment that is less than its charges. If CONTRACTOR or Enrollee receives a reduced primary payment because of failure to file a proper claim with the primary payor, the LME/PIHP secondary payment may not exceed the amount or Negotiated Fee Ratethat would have been payable if the primary payer had paid on the basis of a proper claim. Described below are Your Coinsurance CONTRACTOR must inform the LME/PIHP that a reduced payment was made, and Out of Pocket Maximumsthe amount that would have been paid if a proper claim had been filed. CONTRACTOR shall xxxx the LME/PIHP for third party co-pays and/or deductibles only as permitted by Controlling Authority.