TERMS AND CONDITIONS OF PAYMENT GHI MEDICARE PRIVATE FEE FOR SERIVCE PLAN TOTAL FREEDOM, NATIONAL FREEDOM AND NATIONAL FREEDOM PLUS REQUIREMENTS: • Providers who render service to GHI Medicare Private Fee for Service Plan members must be licensed or certified by the State, acting within the scope of that license or certification, and have not been sanctioned nor opted out of Medicare, Providers cannot be Federal healthcare providers, such as a Veteran’s Administration provider. • The provider must comply with all Medicare and other federal laws, rules and regulations applicable to the Medicare Advantage program and/or covered services, including laws, rules and regulations pertaining to patient privacy and confidentiality and HIPAA. • Facility providers agree to comply with the Medicare regulatory requirements to issue Notice of Medicare Non-coverage (NOMNC), Detailed Explanation of Medicare Non-coverage (DENC) and (NODMAR) Notice of Discharge and Medicare Appeals Rights (hospitals and facilities). • The provider must follow the standards for patient rights as outlined in GHI’s Member’s Rights and Responsibilities. The information may be accessed on GHI’s website at www.ghi.com or by contacting GHI’s or customer service department. COMPENSATION AND CLAIMS SUBMISSION For each Plan Service rendered to a member of the GHI Private fee for Service Plans, the maximum compensation to providers is the Medicare Fee For Service rate schedule applicable in the geographic area where the service was rendered There are three deeming criteria that need to be met in order to do this: 1. The provider knows in advance of treatment that the member is part of the Plan (This can be done when the member shows their member identification card.) 2. The provider has reasonable access to the plans Terms and Conditions of Payment (accessed through the website at www.ghi.com or by calling the plan at provider services department on 1-877-444-7195) 3. The provider treats the member. Providers cannot balance bill members, and can only collect from members the cost- sharing amount applicable under the member’s plan. The provider agrees that under no circumstances, including, but not limited to non- payment by GHI, insolvency of GHI or breach of the Terms and Conditions of Participation will the Provider or the Provider’s assignees and/or subcontractors bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons having authority to act on behalf of the member, for covered services. The provision does not prohibit a Provider from collecting charges for non-covered services agreed to in advance in writing by the member or cost-sharing amounts applicable under the plan. GHI will process all claims according to original Medicare billing rules, current Medicare fee schedules, prospective payment requirements, national and local coverage determination rules. Providers submitting clean claims for covered services will receive the current Medicare allowable charge less any applicable GHI member cost sharing amounts. A clean claim is defined as one with no impropriety, defect or lack of any substantiating documentation. Non-clean claims are returned to the provider with a request for additional information that is needed to process the claim. If an original Medicare allowable charge does not exist, the Provider will be paid an estimated Medicare payment amount, and may collect only applicable GHI cost- sharing amounts. Providers must submit claims using original Medicare’s coding and billing rules/requirements. Providers must certify that the information submitted is accurate and complete, to the best of their knowledge. Claims Claims for covered services rendered to Members shall be submitted to the Plan in accordance with the instructions as found on the Member’s identification card. Member’s eligible for benefits under the GHI Medicare Private Fee for Service plans will be required to present to Provider an ID card which shall contain information necessary to verify member eligibility, terms and conditions of payment, service coverage and claims submission procedures. Providers can submit their claims electronically through Emdeon. The payer ID number : 22937 Paper claims can be sent to GHI Medicare Private Fee for Service JAF Station P.O. Box 1466 New York, NY 10116-1466 GHI reserves the right to amend the Rate Schedules for covered services according to the changes and amendments made by Original Medicare. Coordination Of Benefits Provider shall cooperate with GHI in the implementation of coordination of benefits policy. Provider agrees to make reasonable efforts to determine if a Covered Person is covered under a health insurance plan in addition to the GHI Medicare Private Fee for Service Plans, or if the requested services are covered under Worker’s Compensation or automobile insurance. In the event that the Covered Person or services rendered to a Covered Person are covered under any such plan or insurance (“Non-Plan Insurance”), Provider shall submit a claim to GHI or the Plan only if (i) the GHI Medicare Private Fee for Service Plan, rather than the Non-Plan Insurance, is the primary payer, or (ii) Provider has received from the Non-Plan Insurance an explanation of benefits or other statement of payment or non-payment. GHI Claims The Provider shall submit, in accordance with GHI’s claims procedure, a GHI Claim within three hundred sixty five (365) days after a Plan Service is rendered or, if the Non- Plan Insurance is the primary payer, within thirty (30) days after receipt from the Non- Plan Insurance an explanation of benefits or other statement of payment or non- payment. In no event may a claim be submitted more than three hundred sixty-five days from the date of service. Where the Non-Plan Insurance is primary, the GHI Claim shall be accompanied by Non-Plan Insurance’s explanation of benefits or other statement of payment or non-payment. GHI shall make timely payment in accordance with Federal law. Payment Dependent On Eligibility Status Except for services necessary to treat an “emergency condition,” as defined under Federal law, prior to providing services to a person who claims to be a Covered Person, Provider shall verify with GHI the enrollee’s status as a Covered Person and other conditions of coverage. Except as otherwise required by law, GHI is not required to compensate Provider for services rendered (i) prior to or without such verification or confirmation, or (ii) after Provider has been informed that the person is not, or is no longer, a Covered Person, or that coverage is otherwise not available. Payment For Covered Services Only GHI is responsible only for payment for Plan Services that meet all conditions of coverage under the GHI Medicare Private Fee for Service Plan (“Covered Services”), including conditions that relate to medical necessity, as defined by Original Medicare. Under no circumstances shall Provider bill or seek payment from a Covered Person for a service for which payment is denied or reduced as a result of a failure of the Provider to comply with utilization management requirements. Billing Covered Persons The Provider shall not bill or seek payment from a Covered Person for services rendered except: i. payment for services which are not Plan Services, provided Provider has informed the Covered Person of the charges prior to performing the services; ii. the amount of co-payment the Covered Person is required to make under his/her Plan; iii. the applicable amount of coinsurance, which shall be calculated on the basis of the Medicare Allowable Fee Schedule; iv. the applicable amount of deductible, which shall not exceed the Medicare Allowable Fee Schedule v. where a Plan Service is determined not to be a Covered Service, Provider may collect from the Covered Person provided that Provider, prior to rendering the service, has given the Covered Person a written notice that the Covered Person, rather than GHI or the Plan, would be responsible for payment. Except as specifically permitted above, Provider shall not bill, charge or otherwise seek payment from a GHI Medicare Private Fee for Service Plan enrollee under any circumstances, including a failure by GHI to make payment to Provider. Method Of Calculation Of Payment And Adjustment The Parties agree to the following: (i) Method of Calculation. The amount to be paid on a claim for a Covered Service shall be calculated on the basis of the applicable Medicare Fee For Service Fee Schedule for the geographic area where the services were rendered. All calculation, recalculation or adjustment of claims payment, including the application of coding system, shall be made in accordance with methodologies and standards prevailing in the industry. Upon request, GHI shall provide Provider with an explanation of the basis on which a claim is adjudicated, including the method of calculation, recalculation or adjustment. (ii) Time Period for Adjustment and Calculation. Claims shall be promptly adjudicated and paid within the timeframe mandated under Federal law. If the adjudication of a claim requires information beyond the information contained in the claim, GHI shall notify Provider within thirty (30) calendar days after receipt of the claim. GHI shall make payment to Provider within forty-five (45) days after receipt of all information necessary to accurately adjudicate and calculate the claim. GHI and Provider each agree to make a good faith effort to review claims payments made or received as soon as possible. Adjustment or recalculation, or request for adjustment or recalculation, shall be made within one year after adjudication. All recalculations and readjustments shall be completed promptly after receipt of the necessary information. (iii) Record and Information. Claims adjudication shall be made on the basis of claims information submitted by Provider and, where appropriate, supplemented by information contained in the Covered Person’s medical record. If GHI and Provider disagree on the adjudication result of a claim, each Party shall, upon the other’s request, provide the other with information, records or other documentation it relies upon to reach its position. (iv) Incorrect or Incomplete Records. Provider shall make a good faith effort to ensure the accuracy and completeness of claims information, including a complete, accurate recording of all diagnoses the enrollee may have on the provider claim form. If in reviewing claims submitted by Provider, GHI becomes aware of an inaccurate or incomplete item, GHI shall seek clarification or additional information from Provider. Upon receipt of the necessary information, GHI shall correct or complete the item in question and, if appropriate, recalculate or adjust payment accordingly so that it is within the one (1) year period set forth in (ii) above. The Parties shall cooperate with each other to resolve any disagreement on the accuracy or completeness of any item contained in the claim records. (v) Excluded Claims. The terms of this paragraph expressly exclude any and all claims which relate to fraud, abuse, upcoding, unbundling, and other improper billing acts or omissions. (vi) Overpayment. In the event Provider receives payment which is not due or otherwise payable under this Agreement (“Overpayment”), Provider shall promptly refund the Overpayment. If Provider disagrees with a determination of an Overpayment, Provider must submit, within thirty (30) days after receipt of a notification of the determination, a written explanation along with all supporting documents. If Provider fails to comply with these provisions, GHI or the applicable Plan may deduct the Overpayment from any amounts payable to Provider. Provider acknowledges that provisions contained in this Section apply to Overpayment owed GHI or an enrollee in the GHI Medicare Private Fee for Service Plan. (vii) Payment Dispute. Providers have appeal rights under GHI’s PFFS plan. Any payment disputes, including disputes regarding deductions shall be resolved in the first instance through GHI’s grievance and appeals processes.
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