SHJ25-014 MOLINA HEALTHCARE INTERIM AGREEMENT- PARTIALLY EXECUTED

Home Browse Search

Plan. Health Plan will not prohibit, discourage, or penalize Provider if otherwise practicing in compliance with the law from advocating on behalf of a Member with Health Plan. Members are free to contract at any time to obtain any health care services outside their Health Plan on any terms or conditions the Members choose. Nothing in this section shall be construed to authorize Provider to bind Health Plan to pay for any service. 10. Health Plan does not preclude or discourage Member or those paying for their coverage from discussing the comparative merits of different health carriers with Provider. This prohibition specifically includes prohibiting or limiting Providers participating in those discussions even if critical of a Health Plan. 11. Provider will make health records available to appropriate state and federal authorities involved in assessing the quality of care or investigating complaints, grievances, appeals or review of any adverse benefit determinations of Members subject to applicable state and federal laws related to the confidentiality of medical or health records. Provider is required to cooperate with audit reviews of encounter data in relation to the administration of Health Plan risk adjustment and reinsurance programs. 12. Provider shall famish Covered Reentry Initiative Services to Members without regard to the Member's enrollment in Health Plan as a private purchaser of the plan or as a participant in publicly financed programs of health care services. This requirement does not apply to circumstances when Provider should not render services due to limitations arising from lack of training, experience, skill, or licensing restrictions. 13. Provider may, in good faith, report to state or federal authorities any act or practice by Health Plan that jeopardizes Member health or welfare or that may violate state or federal law. 14. Terms and Conditions of Payment a. For Covered Reentry Initiative Services provided to Members, Health Plan shall pay Provider, and Provider shall pay any of its subcontractors, as soon as practical but subject to the following minimum standards including any applicable federal regulations (i.e. 42 CPR 422.520(b)): i. Ninety-five (95%) percent of the monthly volume of Clean Claims shall be paid within thirty (30) days of receipt by Health Plan or Health Plan's agent; ii. Ninety-five percent (95%) of the monthly volume of all Claims shall be paid or denied within sixty (60) days of receipt by Health Plan or Health Plan's agent; iii. Ninety-nine percent (99%) of the monthly volume of Clean Claims shall be paid within ninety (90) calendar days of receipt, except as agreed to in writing by the parties on a Claim -by -Claim basis. b. A Claim is a bill for services, a line item of service or all services for one Member within a bill. c. The date of receipt of a Claim is the date Health Plan or Health Plan's agent receives either written or electronic notice of the Claim. d. The date of payment is the date of the check or other form of payment. e. Health Plan shall establish a reasonable method for confirming receipt of Claims and responding to Provider inquiries about Claims. f. For those State products/programs covered by the Washington Administrative Code (WAC), failure of Health Plan to abide by the timely Claims payment standards delineated in WAC 284-170-431(2) shall result in a requirement to pay interest on undenied and unpaid Clean Claims more than sixty-one days old until Health Plan meets the standards under that subsection. Interest shall be assessed at the rate of one percent per month and shall be calculated monthly as simple interest prorated for any portion of a month. Health Plan shall add the interest payable to the amount of the unpaid claim without the necessity of Provider submitting an additional claim. g. When Health Plan issues payment in Provider's name and the Member's name, Health Plan shall make Claim checks payable in the name of the Provider first and the Member second. MHWCBHSSCA.082025 Revised Aug 2025 (M11W) Page 10 of 12