Timely Payments to Providers. The Contractor shall make payments to Providers for Covered Services on a timely basis consistent with the Claims Payment Procedure described at 42 U.S.C. Section 1396a(a)(37)(A), unless the Provider and the Contractor agree to an alternate payment schedule. Complaints or disputes concerning payments for the provision of services as described in this paragraph shall be subject to the Contractor's Provider grievance resolution system. The Contractor shall pay for all appropriate Emergency Services rendered by a Provider with whom the Contractor does not have arrangements within thirty (30) days of receipt of a complete and correct claim. If the Contractor determines it does not have sufficient information to make payment, the Contractor shall request all necessary information from the Provider within thirty (30) days of receiving the claim, and shall pay the Provider within thirty (30) days after receiving such information. Such payment shall be made at the same rate the Department would pay for such services according to the level of services provided. The Contractor shall pay for all authorized Post-Stabilization services rendered by a non-Affiliated hospital Provider at the same rate the Department would pay for such services unless a different rate was agreed upon by the Contractor and Provider. Authorized Post-Stabilization services include such services rendered under the circumstances described in Section 70(c)(2) of the Illinois Managed Care Reform and Patient Rights Act. The Contractor shall accept claims from non-Affiliated Providers for at least one (1) year after the date the services are provided. The Contractor shall not be required to pay for claims initially submitted by such Providers more than one (1) year after the date of service.
Timely Payments to Providers. Contractor shall make payments to Providers (including the fiscal agent making payments to Personal Assistants under the HCBS waivers. See Attachment XX) for Covered Services on a timely basis consistent with the Claims Payment Procedure described at 42 U.S.C. § 1396a(a)(37)(A) and 215 ILCS 5/368a. Complaints or disputes concerning payments for the provision of services as described in this Section 5.25 shall be subject to Contractor’s Provider grievance resolution system. Contractor must pay 90 percent (90%) of all Clean Claims from Providers for Covered Services within thirty (30) days following receipt. Contractor must pay 99 percent (99%) of all Clean Claims from Providers for Covered Services within ninety (90) days following receipt. For purposes of this Section, a “Clean Claim” means a claim from a Provider for Covered Services that can be processed without obtaining additional information from the Provider of the service or from a Third Party, except that it shall not mean a claim submitted by or on behalf of a Provider who is under investigation for Fraud or Abuse, or a claim that is under review for determining whether it was Medically Necessary. For purposes of an Enrollee’s admission to a NF, a “Clean Claim” means that the admission is reflected on the patient credit file that Contractor receives from the Department. Contractor will not be considered to be in breach of this Section, and the Department will not impose a monetary sanction pursuant to Section
Timely Payments to Providers. Contractor shall make payments to Providers for Covered Services on a timely basis consistent with the Claims Payment Procedure described at 42 U.S.C. § 1396a(a)(37)(A) and Illinois Public Act 91-0605. Complaints or disputes concerning payments for the provision of services as described in this Section 5.25 shall be subject to Contractor’s Provider grievance resolution system. Contractor must pay 90 percent (90%) of all Clean Claims from Providers for Covered Services within thirty (30) days following receipt. Contractor must pay 99 percent (99%) of all Clean Claims from Providers for Covered Services within ninety (90) days following receipt. For purposes of this Section, a ―Clean Claim‖ means a claim from a Provider for Covered Services that can be processed without obtaining additional information from the Provider of the service or from a Third Party, except that it shall not mean a claim submitted by or on behalf of a Provider who is under investigation for Fraud or Abuse, or a claim that is under review for determining whether it was Medically Necessary. Contractor will not be considered to be in breach of this Section, and the Department will not impose a monetary sanction pursuant to Section 7.16.14 for Contractor’s failure to meet the requirements of this Section, if such purported breach or failure occurs at a time when the Department has not paid any of the required Capitation to Contractor for two (2) consecutive months.
