Asuris Agreement - Laserfiche WebLink

Home Browse Search

status, age or sex. Medical Group will include the non-discrimination compliance provision of this clause in all subcontracts entered into to fulfill its obligations under this Agreement. Ill. PAYMENT FOR MEDICAL SERVICES 3.1 PROVIDER COMP!:; SATION, -Medical Group will be compensated for Medically Necessary Covered Services provided to Members in accordance with the compensation arrangements for the applicable Provider Network and the terms of Members' Health Plans. The compensation arrangements for each Provider Network in which Medical Group is a Participating Provider is set forth in exhibits and addenda attached hereto and incorporated herein. The Medical Group agrees to accept the compensation set forth In the payment exhibits as payment In full for Covered Services provided to Members, whether that amount is paid in whole or in part by the Company, the Member or by any combination of payers. The Company reserves the right to establish and alter the payment methodology and levels from time to time with ninety (90) days prior notice. Acceptance of reimbursement based on new payment levels or methodology constitutes consent The Company shaR pay claims as soon as practical, but subject lo the following minimum standards -(1) the Comp1my shall pay 95% of the monthly volume of clean claims within thirty (30) days of receipt by the Company; and (2) the Company shall pay or deny 95% of the monthly volume of all claims within sixty (60) days of receipt by the Company. For purposes of this Section 3.1, a "clean claim" means a claim that has no defect or impropriety, including any lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim under applicable Washington law. To the extent required by Washington law, the Company shall pay simple interest at the rate of one (1%) percent per month on payable, clean claims not paid by the Company within sixty-one (61) days of receipt. Such interest shall be calculated based on the amount to be paid to the Medical Group for the Covered Services and shall be added to the Medical Group's reimbursement without further claim submission from the Medical Group. Claims for services provided to Members pursuant to a contract With, or on behalf of, the federal government, Including but not limited to the Federal Employees Health Benefits Program (FEHBP), shall not be subject to Interest set forth In this Section 3.1. 3.2 COMPl;NSATION FOR REFE~ LS -Medical Group agrees not to accept any compensation in return for referring any Member to a Medical Group for the furnishing of any item or service payable by Company. Medical Group also agrees to refer Members to providers In accordance with applicable state law and the laws and regulations of the Medicare program. 3.3 MEMBER IDEN Tlf_K;.8IUW. -Medical Group wlll be responsible for establishing the identity of all patients who present themselves as Members in any Health Plans and will promptly report to Company any apparent abuse of the privileges of such Health Plans. 3.4 e].!J.JNG fOBPB.QVIDE R SEfMCtS -Medical Group agrees to submit claims for Covered Services electronically or as prescribed by company or required by law. Claims should be submitted within thirty (30) days of the dale of services and, in any event, shall be submitted no later than twelve (12) months from the date that Members receive services. Claims not submitted within twelve (12) months of date of service shall be disallowed and the Medical Group shall not bill the Member or Company for services or supplies associated with such claims. The Medical Group shall not bill the Company for more than the Medical Group's usual and customary fee for the services rendered, nor shall the Medical Group bill services provided to Members al a rate higher than the Medical Group bills services provided to persons without health care coverage. The Medical Group agrees to abide by Company directives, whether communicated by the Company through its Administrative Manual or other communications and publications. Asurla MGA Agreement (Rev. 06120171 A1881885'4AA Page 5 of 20