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First Choice Agreement (2)
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05. May
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2018-05-15 10:00 AM - Commissioners' Agenda
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First Choice Agreement (2)
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Last modified
7/18/2018 11:09:02 AM
Creation date
7/18/2018 11:08:32 AM
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Meeting
Date
5/15/2018
Meeting title
Commissioners' Agenda
Location
Commissioners' Auditorium
Address
205 West 5th Room 109 - Ellensburg
Meeting type
Regular
Meeting document type
Fully Executed Version
Supplemental fields
Alpha Order
e
Item
Request to Approve a Preferred Provider/Group Agreement with First Choice Health Network
Order
5
Placement
Consent Agenda
Row ID
44613
Type
Agreement
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Provider agrees to submit Clean Claims for Covered Services rendered to Participants on standard UB-04 and <br />CMS-1500 forms, or successors to such forms. Completed UB-04 and CMS-1500 forms shall be submitted <br />electronically or to the address set forth on the Participant's Benefit Plan identification card. Provider agrees to bill <br />its usual and customary charges for the services rendered, to properly and accurately complete all required <br />Provider, Participant, service, and procedure information on the claim form, and to accept payment in full as <br />described in Section 2.14 of this Agreement. In submitting claims pursuant to this Section, Provider shall certify <br />that all data submitted is accurate and truthful. <br />4.1.1 Claims shall be submitted at the earliest possible date after the date Covered Services are rendered . <br />4.1.2 Payers are not required by FCHN to pay a claim if FCHN or the Payor receives the claim more than <br />three-hundred-sixty-five (365) calendar days after the date the Covered Service was rendered, or sixty (60) <br />calendar days after Provider first receives notice that Payor is a secondary payer under applicable coordination of <br />benefits procedures, whichever shall be later. <br />4.1.3 Provider may submit, within the timely filing period described in Section 4.1.2 above, corrections to <br />claims that were submitted with incomplete or invalid information. Incomplete means that information was <br />missing from the claim, and invalid means that the information submitted was illogical, incorrect, or did not <br />conform to the required claim format. Payers are not required by FCHN to pay corrected claims received by <br />FCHN or any Payor more than three hundred sixty-five (365) calendar days after the date the Covered Service <br />was rendered, or sixty (60) calendar days after Provider first receives notice that Payor is a secondary payer <br />under applicable coordination of benefits procedures, whichever shall be later. <br />4.1.4 Provider agrees that requests for adjustments to claims that have been paid or denied, where the claim <br />submittal failed to include a particular item or service or was otherwise in error, must be received by Payers within <br />three hundred sixty-five (365) calendar days after the date the claim was denied or an initial payment was made <br />for the claim. Payers are not required by FCHN to make payments for claims adjustment requests received after <br />such time. Provider shall be under no obligation to refund incorrect claims payments requested by Payers or <br />FCHN more than three hundred sixty-five (365) calendar days after the date an initial payment was made for the <br />claim. <br />4.2 Payment of Claims <br />FCHN-PRO-042016 <br />FCHN shall require all Payers to pay Provider pursuant to Schedule B of this Agreement in accordance with the <br />applicable Benefit Plan, as soon as practical, subject to the following minimum standards: <br />4.2.1 Ninety-five percent (95%) of the monthly volume of clean claims shall be paid within thirty (30) days of <br />receipt; and <br />4.2.2 Ninety-five percent (95%) of the monthly volume of all claims shall be paid or denied within sixty (60) <br />days of receipt, except as agreed to in writing by the parties on a claim-by-claim basis. <br />4.2.3 The receipt date of a claim is the date Payor receives either written or electronic notice of the claim. <br />4.2.4 Claims may be subject to code review software or correct coding edits. FCHN will request that Payers <br />inform FCHN of code review or correct coding software and most frequent claims editing issues for <br />FCHN as needed to facilitate Provider education and training. <br />FCHN is not the guarantor of, or in any way responsible to Providers for, any claims payments, including charges <br />and interest due if applicable. FCHN shall meet with Provider as needed to discuss and review FCHN Payers <br />accounts receivable and to reasonably assist Provider in Provider's efforts to collect payments due and owing <br />from any such Payor as determined by FCHN to be appropriate. <br />These standards do not apply to claims about which there is substantial evidence of fraud or misrepresentation by <br />Provider or Participants, or instances where the Payor has not been granted reasonable access to information <br />under the Provider's control.
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