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3.6.3. When Payer issues payment in Provider or Contracted Provider and Covered Person names, <br />Payor shall make claim checks payable in the name of Provider or Contracted Provider first and Covered Person <br />second. <br />3.6.4. Claim denials shall be communicated to Provider or Contracted Provider and shall include <br />the specific reason why the claim was denied. If the denial is based upon Medical Necessity or similar grounds, then <br />Payor upon request of Provider or Contracted Provider must also promptly disclose the supporting basis for the <br />decision. <br />3.6.5. Payer shall be responsible for ensuring that any person acting on behalf of or at the direction <br />of Payor or acting pursuant to Payor standards or requirements complies with these billing and claim payment <br />standards. <br />3.6.6. The standards in this Section 3.6 do not apply in the following circumstances: to claims about <br />which there is substantial evidence of fraud or misrepresentation by Provider, Contracted Providers or Covered <br />Persons; in instances where Payer or Company has not been granted reasonable access to information under <br />Contracted Provider's control; or if the failure to comply is occasioned by any act of God, bankruptcy, act of a <br />governmental authority responding to an act of God or other emergency, or the result of a strike, lockout, or other <br />labor dispute. <br />3.7. Recovery Rights - Payer. Payer or its delegate shall have the right to immediately offset or recoup <br />any and all amounts owed by Provider or a Contracted Provider to Payer or Company against amounts owed by the <br />Payer or Company to the Provider or Contracted Provider. Provider and Contracted Providers agree that all <br />recoupment and any offset rights under this Agreement will constitute rights of recoupment authorized under State <br />or federal law and that such rights will not be subject to any requirement of prior or other approval from any court or <br />other government authority that may now have or hereafter have jurisdiction over Provider or a Contracted Provider. <br />Notwithstanding the foregoing, except in the case of fraud, a Payor may not request (a) a refund of a payment <br />previously made to satisfy a claim unless Payor does so in writing within 24 months (or within 30 months for reasons <br />related to coordination of benefits) in accordance with RCW 48.43,600 or (b) payment of a contested refund sooner <br />than six months after receipt of the request. This section is not applicable to subrogation claims. <br />3.8. Recovery Rights - Provider. Except in the case of fraud, Provider or a Contracted Provider may not <br />request payment from Company or Payor to satisfy a claim unless it does so in writing within 24 months after the <br />date the claim was denied or payment intended to satisfy the claim was made. In the case of coordination of benefits, <br />Provider or a Contracted Provider must request from Company or Payer within 30 months after original payment was <br />made, any additional balances owed. Additional payment cannot be requested any sooner than six months after <br />request is made. This section is not applicable to subrogation claims. <br />ARTICLE IV - RECORDS AND INSPECTIONS <br />4.1. Records. Each Contracted Provider shall maintain medical, financial and administrative records <br />related to items or services provided to Covered Persons, including but not limited to a complete and accurate <br />permanent medical record for each such Covered Person, in such form and detail as are required by applicable <br />Regulatory Requirements and consistent with generally accepted medical standards. Such records shall be maintained <br />for a minimum of 10 years after final payment is made under this Agreement. However, when an audit, litigation, or <br />other action involving records is initiated prior to the end of said period, records shall be maintained for a minimum <br />of 10 years following resolution of such action. Medical records must support claims submitted to Company for <br />payment in accordance with accepted standards for claims coding as interpreted and applied by the Payor and <br />regulatory authorities. <br />4.2. Access. Provider and each Contracted Provider shall provide access to their respective books and <br />records to each of the following, including any delegate or duly authorized agent thereof, subject to applicable <br />PPA WA - Kittitas County Public Health - 05.07.2025 - ICMProviderAgreement 360268 Page 10 of 24 <br />