276/277 Health Care Claim Status. Transaction Standard for Health Care Claim Status and Response – This transaction is used by the FFS provider to get the status of a claim.
276/277 Health Care Claim Status Sample Clauses
Related to 276/277 Health Care Claim Status
Extended Health Care Plan (a) The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable Extended Health Care Plan.
Pharmacy Benefits - Prescription Drugs and Diabetic Equipment or Supplies from a Pharmacy This plan covers prescription drugs listed on our formulary and diabetic equipment or supplies bought from a pharmacy as a pharmacy benefit. These benefits are administered by our Pharmacy Benefit Manager (PBM). Our formulary includes a tiered copayment structure and indicates that certain prescription drugs require preauthorization. If a prescription drug is not on our formulary, it is not covered. For specific coverage information or a copy of the most current formulary, please visit our website or call our Customer Service Department. Prescription drugs and diabetic equipment or supplies are covered when dispensed using the following guidelines: • the prescription must be medically necessary, consistent with the physician’s diagnosis, ordered by a physician whose license allows him or her to order it, filled at a pharmacy whose license allows such a prescription to be filled, and filled according to state and federal laws; • the prescription must consist of legend drugs that require a physician’s prescription under law, or compound medications made up of at least one legend drug requiring a physician’s prescription under law; • the prescription must be dispensed at the proper place of service as determined by our Pharmacy and Therapeutics Committee. For example, certain prescription drugs may only be covered when obtained from a specialty pharmacy; and • the prescription is limited to the quantities authorized by your physician not to exceed the quantity listed in the Summary of Pharmacy Benefits. Prescription drugs are subject to the benefit limits and the amount you pay shown in the Summary of Pharmacy Benefits.
Accident Prevention Health and Safety Committee (a) The Employer and the Union agree that they mutually desire to maintain standards of safety and health in the Hospital in order to prevent accidents, injury and illness. its responsibilities under the applicable legislation, the Hospital agrees to accept as a member of its Accident Prevention Health Safety Committee at least one representative selected or appointed by the Union from amongst bargaining unit employees. The Union agrees to appoint one regular member and one alternate member in order to ensure continuous representation on this committee at all times. Such Committee shall identify potential dangers and hazards, institute means of improving health and safety programs and recommend actions to be taken to improve conditions related to safety and health. The Hospital agrees to co-operate reasonably in providing necessary information to enable the Committee to its functions. Meetings shall be held every second month or more frequently at the call of the Chair if required. The Committee shall maintain minutes of all meetings and make the same available for review. Any representative appointed or selected in accordance with hereof shall serve for a term of one calendar year from the date of which may be renewed for further periods of one year. Time off for such representative(s) to attend meetings of the Accident Prevention Health Safety Committee in accordance with the foregoing shall be granted and time so spent attending such meetings shall be deemed to be work time for which the representative(s) shall be paid by the Hospital at his regular or premium rate as may be applicable. The Union agrees to endeavour to obtain the full co- operation of its membership in the observation of all safety rules and practices. Pregnant employees may request to be transferred from their current duties if, in the professional opinion of the employee's physician, the pregnancy may be at risk. If such a transfer is not feasible, the pregnant employee, if she so requests, will be granted an unpaid leave of absence before commencement of the maternity leave referred to in Article Where the Hospital identifies high risk areas where employees are exposed to Hepatitis the Hospital will provide, at no cost to the employees, a Hepatitis B vaccine.
HEALTH CARE PLANS Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.
Submitting False Claims; Monetary Penalties Pursuant to San Francisco Administrative Code §21.35, any contractor, subcontractor or consultant who submits a false claim shall be liable to the City for the statutory penalties set forth in that section. A contractor, subcontractor or consultant will be deemed to have submitted a false claim to the City if the contractor, subcontractor or consultant: (a) knowingly presents or causes to be presented to an officer or employee of the City a false claim or request for payment or approval; (b) knowingly makes, uses, or causes to be made or used a false record or statement to get a false claim paid or approved by the City; (c) conspires to defraud the City by getting a false claim allowed or paid by the City; (d) knowingly makes, uses, or causes to be made or used a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the City; or
How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.
Medical Benefits - Prescription Drugs Administered by a Provider (other than a pharmacist) This plan covers prescription drugs as a medical benefit, referred to as “medical prescription drugs”, when the prescription drug requires administration (or the FDA approved recommendation is administration) by a licensed healthcare provider (other than a pharmacist). Please note: Specialty prescription drugs meeting these requirements or recommendations are covered as a pharmacy benefit and not a medical benefit. These medical prescription drugs include, but are not limited to, medications administered by infusion, injection, or inhalation, as well as nasal, topical or transdermal administered medications. For some of these medical prescription drugs, the cost of the prescription drug is included in the allowance for the medical service being provided, and is not separately reimbursed.
Maximum Statutory Penalties 8. Defendant understands that the charge to which he is pleading guilty carries the following statutory penalties:
