Timely Payment Requirement. The MCO must agree to make timely claims payments to both its contracted and non-contracted providers. A claim is defined as a bill for services, a line item of service, or all services for one recipient within a bill. A clean claim is defined as one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. The MCO must pay all clean in-network provider claims for covered services within thirty (30) calendar days of receipt, except to the extent the provider has agreed to later payment in writing. The MCO must pay all electronic out-of-network clean claims within thirty (30) days and all paper out-of-network clean claims within forty (40) days from the date of receipt, except to the extent the provider has agreed to later payment in writing. The MCO must agree to specify the date of receipt as the date the MCO receives the claim, as indicated by its date stamp (including electronic date stamp) on the claim, and date of payment as the date of the check release or other form of payment release to the provider. The MCO must pay in-network providers interest at seven (7) percent per annum, calculated daily for the full period in which the clean claim remains unpaid beyond the thirty (30) day clean claims payment deadline. Interest owed to the provider must be paid on the same date as the claim. The interest paid to the providers will not be reported as a part of the MCO encounter data. This provision does not apply to payments made due to a rate change per Article III, §2.7.9.
Timely Payment Requirement. The MCO must agree to make timely claims payments to both its contracted and non-contracted providers. A claim is defined as a bill for services, a line item of service, or all services for one
Timely Payment Requirement. The MCO must agree to make timely claims payments to both its contracted and non-contracted providers. A claim is defined as a xxxx for services, a line item of service, or all services for one recipient within a xxxx. A clean claim is defined as one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. The MCO will not be held to this requirement should BMS be delayed in its payment to the MCO by a period of more than 15 days. In such a situation, the MCO may delay payment to contracted and non-contracted providers by a period not to exceed the delay in payment from BMS. The MCO must provide payment to affiliated health care providers for items and services covered under this contract on a timely basis, consistent with the claims payment procedures described in section 1902(a)(37)(A) of the Social Security Act and the implementing Federal regulation at 42 CFR 447.45, outlined above, unless the health care provider and organization agree to an alternative payment schedule. The MCO must make timely payments to out-of-network providers for medically necessary, covered services. The MCO must pay at least 90 percent of all clean claims (claims that pass all edits required for payments by the MCO) from subcontractors for covered services within 30 calendar days of receipt and pay at least 99 percent of all clean claims within 90 calendar days of receipt, except to the extent subcontractors have agreed to later payment. The MCO must pay all other claims, except those from providers under investigation for fraud and abuse, within 12 months of the date of receipt. The MCO must agree to specify the date of receipt as the date the agency receives the claim, as indicated by its date stamp on the claim, and date of payment as the date of the check or other form of payment.
