Cost Avoidance Sample Clauses

Cost Avoidance. As provided in Article 8.7, except in certain cases, the Contractor shall attempt to avoid payment in all cases where there is other insurance.

Cost Avoidance. 8.4.2.1 The Contractor shall cost avoid all Claims or services that are subject to payment from a third party health insurance carrier, and may deny a service to a Member if the Contractor is assured that the third party health insurance carrier will provide the service, with the exception of those situations described below in Section 8.4.

Cost Avoidance. 22.4.5.1 When the Contractor is aware of health or casualty insurance coverage before paying for a Covered Service, the Contractor shall avoid payment by promptly (within fifteen (15) Business Days of receipt) rejecting the Provider’s claim and directing that the Claim be submitted first to the appropriate Third Party.

Cost Avoidance. As provided in Article 8.13, except in certain cases, the contractor shall attempt to avoid payment in all cases where there is other insurance. The system should have edits to identify potential other coverage situations and flag the claims accordingly. The edits should include looking for accident indicators, other coverage information from the claims, other coverage information on file for the enrollee, and potential accident/injury diagnoses.

Cost Avoidance. 1. When the contractor is aware of health or casualty insurance coverage prior to paying for a health care service, it shall avoid payment by rejecting a provider's claim and directing that the claim be submitted first to the appropriate third party, or by directing its provider to withhold payments to a subcontractor. 2. If insurance coverage is not available, or if one of the exceptions to the cost avoidance rule discussed below applies, then payment must be made and a claim made against the third party, if it is determined that the third party is or may be liable.

Cost Avoidance. The Contractor shall cost avoid all claims for services that are subject to third-party payment and may deny a service to an enrolled person if it knows that a third party (i.e. other insurer) shall provide the service. However, if a third-party insurer (other than Medicare) requires the enrolled person to pay any copayment, coinsurance or deductible, the Contractor is responsible for making these payments, even if the services are provided outside of the Contractor's network. The Contractor's liability for coinsurance and deductibles is limited to what the Contractor would have paid for the entire service pursuant to a written agreement with the Subcontracted Provider or the ADHS/DBHS max cap rate, less any amount paid by the third party. The Contractor shall decide whether it is more cost-effective to provide the service within its network or pay coinsurance and deductibles for a service outside its network. For continuity of care, the Contractor may also choose to provide the service within its network. If the Contractor refers the enrolled person for services to a third-party insurer (other than Medicare), and the insurer requires payment in advance of all copayments, coinsurance and deductibles, the Contractor shall make such payments in advance. If the Contractor knows that the third party insurer shall neither pay for nor provide the Covered Service, and the service is medically necessary, the Contractor shall not deny the service nor require a written denial letter. If the Contractor does not know whether a particular service is covered by the third party, and the service is medically necessary, the Contractor shall contact the third party and determine whether or not such service is covered rather than requiring the enrolled person to do so. The requirement to cost avoid applies to all AHCCCS Title XIX and Title XXI covered services. In emergencies, the Contractor shall provide the necessary services and then coordinate payment with the third-party payer. The Contractor shall also provide medically necessary transportation so that enrolled persons can receive third-party benefits. Further, if a service is medically necessary, the Contractor shall ensure that its cost avoidance efforts do not prevent an enrolled person from receiving such service and that the enrolled person shall not be required to pay any coinsurance or deductibles for use of the other insurer's providers.

Cost Avoidance. Indicate the dollar amount you denied as a result of your knowledge of other insurance that is available for the enrollee. Amount Cost Avoided:

Cost Avoidance. The Contractor shall take reasonable measures to determine all legally liable parties. This refers to any individual, entity or program that is or may be liable to pay all or part of the expenditures for covered services. The Contractor shall cost-avoid a claim if it has established the probable existence of a liable party at the time the claim is filed. Establishing liability takes place when the Contractor receives confirmation that another party is, by statute, contract, or agreement, legally responsible for the payment of a claim for a healthcare item or service delivered to a member. If the probable existence of a party’s liability cannot be established the Contractor must adjudicate the claim. The Contractor must then utilize post payment recovery which is described in further detail below. If AHCCCS determines that the Contractor is not actively engaged in cost avoidance activities the Contractor shall be subject to sanctions.

Cost Avoidance. In accordance with Department requirements in the Managed Care Policy and Procedure Guide, the CONTRACTOR must have processes, methods and resources necessary to receive TPL data from the Department and to identify third-party coverage for its members. This information will be used in managing Provider payment at the front end before the Claim is paid. The CONTRACTOR must have appropriate edits in the Claims system to ensure that Claims are properly coordinated when other insurance is identified. The CONTRACTOR’s Medicaid reimbursement and Third Party payment cannot exceed the amount the Provider has agreed to accept as payment in full from the Third Party payer. If the probable existence of TPL has been established at the time the Claim is filed, the CONTRACTOR must reject the Claim and return it to the Provider for a determination of the amount of any TPL. The CONTRACTOR shall xxxx or inform the Provider to xxxx the third-party coverage within thirty (30) Days of identification. For certain services, the CONTRACTOR should not cost-avoid Claims and will pursue recovery under a policy known as “Pay & Chase”. See the Managed Care Policy and Procedure Guide for list of services. While Providers of such services are encouraged to file with any liable Third Party before the CONTRACTOR, if they choose not to do so, the CONTRACTOR will pay the Claims and xxxx liable Third Parties directly through a Benefit Recovery Program. The CONTRACTOR shall deny payment on a Claim that has been denied by a known Third Party payer, as defined in Section 10 of this contract, when the reason for denial is the Provider or Medicaid Managed Care Member’s failure to follow prescribed Procedures, including but not limited to, failure to obtain Prior Authorization, timely filing, etc. Post-Payment Recovery Post-payment recovery is necessary in cases where the CONTRACTOR has not established the probable existence of a liable Third Party at the time services were rendered or paid for, for members who become retroactively eligible for Medicare, or in situations when the CONTRACTOR was unable to cost-avoid. The CONTRACTOR must have Procedures in place to ensure that a Provider who has been paid by the CONTRACTOR and subsequently receives reimbursement from a Third Party repays the CONTRACTOR either the full amount paid by Medicaid or the full amount paid by the Third Party, whichever is less. CONTRACTOR Post-Payment Recovery Requirements In accordance with Department requirements in the ...