SHJ25-014 MOLINA HEALTHCARE RENEWAL - PARTIALLY EXECUTED

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Claim was made if the request is related to coordination of benefits with another carrier or entity responsible for payment of the Claim. Provider may not request that payment be made any sooner than six (6) months after Health Plan's receipt of the request. Any request for review of denied or underpaid Claims must be submitted to Health Plan in accordance with the requirements stated in this section and conform to the following instructions: i. The request must specify why the Provider believes Health Plan owes the payment. ii. In the case of coordination of benefits, the request must include the name and mailing address of any entity that has disclaimed responsibility for payment. iii. The request must be addressed to the attention of Health Plan's Provider Services Department. iv. The request must clearly indicate "Denied Claims Review Request" or "Adjustment Request"; and, v. The request must include all pertinent information, including, but not limited to, Claim number, Member identifier, denial letter, supporting medical records, and any new information pertinent to the request. vi. Health Plan will render a decision on all disputed Claims within sixty (60) days of receipt of the Claim. vii. Should Provider not be satisfied with Health Plan's decision, Provider may proceed to the mediation steps outlined in the Provider Manual. h. Claims Review and Audit. Provider acknowledges Health Plan's right to review Provider's Claims prior to payment for appropriateness in accordance with industry standard billing rules, including, but not limited to, current UB manual and editor, current CPT and HCPCS coding, CMS billing rules, CMS bundling/unbundling rules, National Correct Coding Initiatives (NCCI) Edits, CMS multiple procedure billing rules, and FDA definitions and determinations of designated implantable devices and/or implantable orthopedic devices. Provider acknowledges Health Plan's right to conduct such review and audit on a line -by-line basis or on such other basis as Health Plan deems appropriate, and Health Plan's right to exclude inappropriate line items to adjust payment and reimburse Provider at the revised allowable level. Provider also acknowledges Health Plan's right to conduct utilization reviews to determine medical necessity and to conduct post -payment billing audits. Provider shall cooperate with Health Plan's audits of Claims and payments by providing access to requested Claims information, all supporting medical records, Provider's charging policies, and other related data. Health Plan shall use established industry claims adjudication and/or clinical practices, state and federal guidelines, and/or Health Plan's policies and data to determine the appropriateness of the billing, coding and payment. i. Payments which are the Responsibility of a Capitated Provider. Provider agrees that if Provider is or becomes a party to a subcontract or other agreement with another provider contracted with Health Plan who receives capitation from Health Plan and is responsible for paying for Covered Services through subcontract arrangements ("Capitated Provider"), Provider shall look solely to the Capitated Provider, and not Health Plan, for payment of Covered Services provided to Members that are covered by Health Plan's agreements with such Capitated Providers. j. Timely Submission of Encounter Data. Provider understands Health Plan may have certain contractual reporting obligations that require timely submission of Encounter Data. If a Clean Claim does not contain the necessary Encounter Data, Provider will submit Encounter Data to Health Plan. This section will survive any termination. 2.9 Compliance with Applicable Law. Provider shall comply with all applicable state and federal laws governing the delivery of Covered Services to Members including, but not limited to, Title XIX and Title XXI of the SSA and Title 42 CFR, Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973; the Balanced Budget Act of 1997; the Americans with Disabilities Act, and Federal Drug and Alcohol Confidentiality Laws in 42 CFR Part 2, 42 U.S.C. § 1396a(a)(43), 1396d(r), and 42 CFR 438.6(i): MHWPROV22.3 MHWPSA/Revised Jan 2024 Page 11 of25