Fully executed agreement - Laserfiche WebLink

Home Browse Search

3.6.3. When Payor iszues payment inProvider or Contracted Provider and Covered Person names, Payor shall make claim checks payable in the name of Provid.er or Contracted Provider first and Covered Person second- 3.6.4. Claim denials shall be cornmunicated to hovider or Conhacted Provider and shall includE the specific reasonwhy the olaim was dsnied. If the denial is based upon Medical Necessity or similar grounds, then Payor upon request of Provider or Contracted Provider must also promptly clisclose the supporting basis for the decision. 3.6.5. Payor shall be responsible for ensuring that any petson acting on behalf of or at the direction of Payor or acting pursuant to Payor standards or requirements complies with these billing and claim payment standarcls. 3.6.6, The standards inthis Section 3.6 do not apply inthe folls\a/irig circumstrances: to claims about which there is substantial evidence of fi'aud or misrepresentation by Provider, Contraoted Providers or Covered Persons; in instances whoro Payor or Company has not been granted reasonable access to information under Contracted hovider's control; or if the failure to comply is occasioned by any act of God, banlcuptcy, act of a governmental authority responding to an act of God or other emergency, or the resuli of a strikg lockout, or other labor dispute. 3.1. Recovery Rishts - Payor. Payor or its delegate shall have the right to immediately offset or recoup any and all amounts owed by Provider or a Contracted Provider to Payor or Company against amounts owed by the Payor or Company to tle Provider or Contracted Provider, Provider and Conkacted Providers agree that all recoupment and any offset rights under this Agreement will constitute rights of recoupment authorized under State or federal law and that zuch rights will not be subject to any requirement of prior or other approval from any court or other govemment authority that nny now have or hereafter have jurisdiotion over Provider or a Contracted ProvidEr. Notwithstancling the foregoing, except in the case of fraud, a Payor may not request (a) a refirnd of a palmrent previously made to satis$' a claim unless Payor does so in writing within 24 months (or within 30 months for reasons relatecl to coordination of benefits) in accordance with RCW 48.43,600 or ft) payment of a contested rsfund sooner than six months afber receipt of the request. This section is not applicable to subrogation claims. 3,8. Recoverv Rights - Provider. Except in the casE of fraud, Provider or a Contracted Provider may not request paynent from Company or Payor to satisfy a slaim unless it does so in writing within 24 months a{ter the date the claim was denied or payment intended to satisfu the ciaim was made. Ir the case of coordkmtion of benefits, Provider or a Contracted Providermust request from Company orPayor within 30 months after original payment was made, any additional balances owed, Additional payment canaot be requested any sooner than six months after request is made. This section is not applicable to subrogation claims, ARTICLE TV . RECORDS AND INSPECTIONS 4.1. Records. Each Contracted Provider shall maintain medical, financial and administrative records related to items or services provided to Covered Persons, including but not limited to a complete and acourate pemtanent medical record for each such Covered Person, in such fonn and detail as are required by applicable Regulatory Requirements and consistent with generally accepted medical standards. Such records shall be maintained for a minimum of i0 years after final paym.ent is made under this Agreement. However, when an audit, litigation, or other action involving records is initiated prior to the end of said period, records shall be maintained for a minimum of 10 years following resolution of such action Medical records must support claims submitted to Company for payment in accordance with accepted standards for claims coding as interpreted and applied by the Payor and regulatory authorities. 4.2. Acces.-s. Provider and each Contracted Provider shall provide access to their respective books and records to eash of the following, including any delegato or duly authorized agent tlrereof, subject to applicable PPA WA - Ifittitas County Public Health - 05.07.2V25 - ICMProviderAgreernenl36026S Page I 0 of 24