Common use of Submission of Claims Clause in Contracts

Submission of Claims. a. 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 LME/PIHP’s secure web based billing system. b. CONTRACTOR’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. below. 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, as indicated on the electronic data records. e. 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 bill 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 service or discharge (whichever is later). f. 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 such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. 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 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 an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General Statutes. i. Billing Diagnosis submitted on claims must be consistent with the service provided. j. 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. k. The LME/PIHP shall not reimburse CONTRACTOR for “never events.”

Submission of Claims. a. Claims must be submitted to the LME/PIHP electronically either through HIPAA Compliant 5010 EDI Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, Sets: 837P – Professional claims, 837I – Institutional claims, or through direct data entry in the LME/PIHP’s secure web based billing 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. b. CONTRACTORLIP’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or 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 submitted more than ninety (90) days after the date of service or discharge (whichever is later) except in the instances denominated in subparagraph 8.esubparagraph8.e. and f. below. The date of receipt is the date the LME/PIHP receives the claim, as indicated on the electronic data records. e. CONTRACTOR may If LIP delays claims due to the subrogation of benefits or the determination of eligibility for benefits for the Enrollee, LIP shall 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 bill the LME/PIHP within ninety (90) days of receipt of notice by the CONTRACTOR LIP 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 service or discharge (whichever is later)Medicaid. f. If CONTRACTOR LIP delays submission of the claims due to the coordination of benefits, subrogation of benefits or the determination of eligibility for benefits for the EnrolleeEnrollee , CONTRACTOR LIP shall submit such claims within thirty ninety (3090) days of the date of from the notice of determination of coverage or payment by the third partyparty up to 180 days from date of service. g. If a claim is denied for reasons other than those stated above in subparagraph 7.e.8.e. and f., and the CONTRACTOR LIP wishes to resubmit the denied claim with additional information, CONTRACTOR LIP must resubmit the claim within ninety (90) days after CONTRACTORLIP’s receipt of the denial. If the CONTRACTOR LIP needs more than ninety (90) days to resubmit a denied claim, CONTRACTOR LIP must request and receive an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General Statutes. i. Billing Diagnosis submitted on claims must be consistent with the service provided. j. 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. k. The LME/PIHP shall not reimburse CONTRACTOR for “never events.”

Submission of Claims. a. 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 LME/PIHP’s secure web based billing system. b. CONTRACTOR’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. below. 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, as indicated on the electronic data records. e. 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 bill ▇▇▇▇ 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 service or discharge (whichever is later). f. 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 such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. If a claim is denied for reasons other than those stated above in subparagraph 7.e., 8.e. and the CONTRACTOR wishes to resubmit the denied claim with additional information, CONTRACTOR must resubmit the claim within ninety (90) days after 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 an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General StatutesManual. i. Billing Diagnosis submitted on claims must be consistent with the service provided. j. 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. k. The LME/PIHP shall not reimburse CONTRACTOR for “never events.”

Submission of Claims. a. 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 LME/PIHP’s secure web based billing system. b. CONTRACTORContractor’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e7.e. below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e7.e. below. 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.e7.e. below. The date of receipt is the date the LME/PIHP receives the claim, as indicated on the electronic data records. e. CONTRACTOR 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 Contractor may bill the LME/PIHP within ninety (90) days of receipt of notice by the CONTRACTOR 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 service or discharge (whichever is later). f. If CONTRACTOR 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 Contractor shall submit such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. If a claim is denied for reasons other than those stated above in subparagraph 7.e., and the CONTRACTOR Contractor wishes to resubmit the denied claim with additional information, CONTRACTOR Contractor must resubmit the claim within ninety (90) days after CONTRACTORContractor’s receipt of the denial. If the CONTRACTOR Contractor needs more than ninety (90) days to resubmit a denied claim, CONTRACTOR Contractor must request and receive an extension from the LME/PIHP before the expiration of the ninety (90) day deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General StatutesManual. i. Billing Diagnosis submitted on claims must be consistent with the service provided. j. 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. k. The LME/PIHP shall not reimburse CONTRACTOR Contractor for “never events.”

Submission of Claims. a. 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 LME/PIHP’s secure web based billing system. b. . CONTRACTOR’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. . Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. . Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. below. 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, as indicated on the electronic data records. e. . 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 bill ▇▇▇▇ 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 service or discharge (whichever is later). f. . 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 such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. . 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 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 an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. . All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General Statutes. i. . Billing Diagnosis submitted on claims must be consistent with the service provided. j. . 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. k. . The LME/PIHP shall not reimburse CONTRACTOR for “never events.”” 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 claim from CONTRACTOR, the 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 request additional information for only a part of 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 reimburse CONTRACTOR for services provided by staff not meeting licensure, certification, credentialing, or accreditation requirements. CONTRACTOR understands and agrees that reimbursement rates paid under this Contract are established by the LME/PIHP. 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 ▇▇▇▇ all applicable third party payors prior to billing the LME/PIHP. Medicaid benefits payable through the LME/PIHP are secondary to benefits payable by a primary payer, including Medicare, even if the primary payer states that its benefits are secondary to Medicaid benefits or otherwise limits its payments to Medicaid enrollees. The LME/PIHP makes secondary payments to supplement the primary payment if the primary payment is less than the lesser of the 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 that would have been payable if the primary payer had paid on the basis of a proper claim. CONTRACTOR must inform the LME/PIHP that a reduced payment was made, and the amount that would have been paid if a proper claim had been filed. CONTRACTOR shall ▇▇▇▇ the LME/PIHP for third party co-pays and/or deductibles only as permitted by Controlling Authority.

Submission of Claims. a. Claims must be submitted to the LME/PIHP electronically either through HIPAA Compliant 5010 EDI Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, Sets: 837P – Professional claims, 837I – Institutional claims, or through direct data entry in the LME/PIHP’s secure web based billing claims system. b. CONTRACTOR. 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. c. . Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. . Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or 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 submitted more than ninety (90) days after the date of service or discharge (whichever is later) except in the instances denominated in subparagraph 8.esubparagraph8.e. and f. below. The date of receipt is the date the LME/PIHP receives the claim, as indicated on the electronic data records. e. CONTRACTOR may . If LIP delays claims due to the subrogation of benefits or the determination of eligibility for benefits for the Enrollee, LIP shall 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 bill the LME/PIHP within ninety (90) days of receipt of notice by the CONTRACTOR LIP 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 service or discharge (whichever is later). f. Medicaid. If CONTRACTOR LIP delays submission of the claims due to the coordination of benefits, subrogation of benefits or the determination of eligibility for benefits for the EnrolleeEnrollee , CONTRACTOR LIP shall submit such claims within thirty ninety (3090) days of the date of from the notice of determination of coverage or payment by the third party. g. party up to 180 days from date of service. If a claim is denied for reasons other than those stated above in subparagraph 7.e.8.e. and f., and the CONTRACTOR LIP wishes to resubmit the denied claim with additional information, CONTRACTOR ▇▇▇ must resubmit the claim within ninety (90) days after CONTRACTOR▇▇▇’s receipt of the denial. If the CONTRACTOR LIP needs more than ninety (90) days to resubmit a denied claim, CONTRACTOR LIP must request and receive an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. . All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General Statutes. i. . Billing Diagnosis submitted on claims must be consistent with the service provided. j. . 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. k. The LME/PIHP shall not reimburse CONTRACTOR for “never events.”

Submission of Claims. a. 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 LMEA. The BH I/PIHP’s secure web based billing system. b. CONTRACTOR’s DD Tailored Plan shall adjudicate claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. below. 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, as indicated on the electronic data records. e. 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 bill 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 service or discharge (whichever is later). f. 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 such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. 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 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 an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LMEBH I/PIHP DD Tailored Plan Provider Operations Manual and Chapter 108C of the North Carolina General StatutesManual. i. B. Billing Diagnosis submitted on claims must be consistent with the service provided. j. C. 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 EnrolleeMember, the specific service may be billed as the aggregate of the units delivered rather than as separate line items. k. D. Claims must be submitted electronically either through HIPAA Compliant Transaction Sets; 837P – Professional claims, 837I – Institutional claims, or the BH I/DD Tailored Plan’s secure web based billing system. E. Contractor’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. F. Parties shall be compliant with the requirements of the National Uniform Billing Committee. G. G.S. 58-3-225. Prompt claim payments under health benefits. The LMEContractor shall submit all claims to the BH I/PIHP DD Tailored Plan for processing and payments within one- hundred-eighty (180) calendar days from the date of covered service or discharge (whichever is later). However, the Contractor’s failure to submit a claim within this time will not invalidate or reduce any claim if it was not reasonably possible for the Contractor to submit the claim within that time. In such case, the claim should be submitted as soon as reasonably possible, and in no event, later than one (1) year from the time submittal of the claim is otherwise required. i. For Medical claims (including BH): a) The BH I/DD Tailored Plan shall within eighteen (18) Calendar Days of receiving a Medical Claim notify the Contractor whether the claim is clean or pend the claim and request from the Contractor all additional information needed to process the claim. b) The BH I/DD Tailored Plan shall pay or deny a clean medical claim at lesser of thirty (30) Calendar Days of receipt of the claim or the first scheduled provider reimbursement cycle following adjudication. c) A medical pended claim shall be paid or denied within thirty (30) Calendar Days of receipt of the requested additional information. ii. For Pharmacy Claims: a) The BH I/DD Tailored Plan shall within fourteen (14) Calendar Days of receiving a pharmacy claim pay or deny a clean pharmacy claim or notify the provider that more b) A pharmacy pended claim shall be paid or denied within fourteen (14) Calendar Days of receipt of the requested additional information. iii. If the requested additional information on a medical or pharmacy pended claim is not submitted within ninety (90) days of the notice requesting the required additional information, the BH I/DD Tailored Plan shall deny the claim per § 58-3-225 (d). a) The BH I/DD Tailored Plan shall reprocess medical and pharmacy claims in a timely and accurate manner as described in this provision (including interest and penalties if applicable). iv. If the BH I/DD Tailored Plan fails to pay a clean claim in full pursuant to this provision, the BH I/DD Tailored Plan shall pay the Contractor interest and liquidated damages. Late Payments will bear interest at the annual rate of eighteen (18) percent beginning on the date following the day on which the claim should have been paid or was underpaid. v. Failure to pay a clean claim within thirty (30) days of receipt will result in the BH I/DD Tailored Plan paying the Contractor liquidated damages equal to one percent (1%) of the total amount of the claim per day beginning on the date following the day on which the claim should have been paid or was underpaid. vi. The BH I/DD Tailored Plan shall pay the interest and liquidated damages from subsections (iv) and (v) as provided in that subsection and shall not reimburse CONTRACTOR for “never eventsrequire the Contractor to requests the interest or the liquidated damages.”

Submission of Claims. a. 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 LME/PIHP’s secure web based billing system. b. CONTRACTORContractor’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. below. 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, as indicated on the electronic data records. e. CONTRACTOR 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 Contractor may bill ▇▇▇▇ the LME/PIHP within ninety (90) days of receipt of notice by the CONTRACTOR 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 service or discharge (whichever is later). f. If CONTRACTOR 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 Contractor shall submit such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. If a claim is denied for reasons other than those stated above in subparagraph 7.e., and the CONTRACTOR Contractor wishes to resubmit the denied claim with additional information, CONTRACTOR Contractor must resubmit the claim within ninety (90) days after CONTRACTORContractor’s receipt of the denial. If the CONTRACTOR Contractor needs more than ninety (90) days to resubmit a denied claim, CONTRACTOR Contractor must request and receive an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General StatutesManual. i. Billing Diagnosis submitted on claims must be consistent with the service provided. j. 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. k. The LME/PIHP shall not reimburse CONTRACTOR Contractor for “never events.”

Submission of Claims. a. 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 LME/PIHP’s secure web based billing system. b. CONTRACTOR’s claims shall be compliant with the National Correct Coding Initiative effective at the date of service. c. Both parties shall be compliant with the requirements of the National Uniform Billing Committee. d. Claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except in the instances denominated in subparagraph 8.e. 8.e below. All claims submitted past ninety (90) days of the date of service or discharge (whichever is later) will be denied and cannot be resubmitted except in the instances denominated in subparagraph 8.e. 8.e below. 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. 8.e below. The date of receipt is the date the LME/PIHP receives the claim, as indicated on the electronic data records. e. 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 bill ▇▇▇▇ 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 service or discharge (whichever is later). f. 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 such claims within thirty (30) days of the date of the notice of determination of coverage or payment by the third party. g. If a claim is denied for reasons other than those stated above in subparagraph 7.e., 8.e. and the CONTRACTOR wishes to resubmit the denied claim with additional information, CONTRACTOR must resubmit the claim within ninety (90) days after 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 an extension from the LME/PIHP before the expiration of the ninety (90) deadline, such extension not to be unreasonably withheld. h. All claims shall be adjudicated as outlined in the LME/PIHP Provider Operations Manual and Chapter 108C of the North Carolina General StatutesManual. i. Billing Diagnosis submitted on claims must be consistent with the service provided. j. 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. k. The LME/PIHP shall not reimburse CONTRACTOR for “never events.”