2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

LegalPrompt Pay by PresbyterianPresbyterian shall make payment in full to providerfor clean claims within the time period specifiedunder applicable state law. (Source: 42 CFR §422.520(b).)By SXC Health Solutions CorporationProvider shall pay participating pharmacies for allclean claims for MA plan enrollees no later than thetime required by Medicare Advantage rules, asapplicable. (Source: 42 CFR s 423.50, MedicareManaged Care Manual, Chapter 11, § 100.4.)Reimbursement – Provider shall update thepricing standard used for reimbursement toparticipating pharmacies every seven days.Payment rate –Provider shall establishpayment rates for plan-covered items andservices, reimburse participating pharmacieson a fee-for-service basis, and makeinformation on payment rates available toproviders.Long-term care claims –Provider shall pay longtermcare pharmacy claims consistent with thetime frames established in Section 42 CFR §423.505(b)(20).Subcontractor Certification of Data Accuracy,Completeness, and TruthfulnessTo the extent applicable to the services providedunder the agreement(s) or this amendment,practitioner/provider warrants and represents, andupon request will certify to Presbyterian and toCMS that all data including, without limitation,encounter data, it submitted to Presbyterian isaccurate, complete, and truthful and agrees tosubmit all data necessary to characterize thecontent of purpose of each encounter with MA planenrollees. (Source: 42 CFR §§ 422.310, 422.504.)Office of the Inspector General ExclusionCertificationProvider shall, and shall require all subcontractorsto, review the Office of Inspector General andGeneral Services Administration exclusions listsupon initially hiring and annually thereafter toensure that any employee or manager responsiblefor administering or delivering Part D or MedicareAdvantage benefits is not excluded from federalhealth care programs. Providers andsubcontractors shall immediately remove anyexcluded employee from work related directly orindirectly to all federal health care programs andtake appropriate corrective actions that anemployee responsible for the administration ofdelivery of any Part D or Medicare Advantagebenefits who is on such lists. Providers andsubcontractors shall annually provide Presbyterianwith written certification of compliance with theserequirements. (Source: 422.752(a)(8); Chapter 9,Sec. 50.2.1.2.)Conflict of Interest CertificationProvider and a subcontractors’ officers, directors,and managers shall annually sign a statement,attestation or certification stating that (1) theindividual has reviewed Presbyterian’s conflict ofinterest policies; (2) the individual has disclosedany potential conflict of interests; and (3) theindividual has obtained management approval to14-142014 Practitioner and Provider Manual - Ver. 3