Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Covered Services described in the State’s Prepaid Mental Health Plan Waiver as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall furnish all Covered Servicesin an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS as set forth in 42 CFR 440.230, and for Enrollees under the age of 21, as set forth in 42 CFR 440, Subpart B.
(C) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(D) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the Enrollee.
(E) The Contractor may place appropriate limits on a service on the basis of criteria applied under the State Plan such as Medical Necessity, or for the purpose of utilization control, provided:
(1) the services furnished can reasonably be expected to achieve their purpose; and
(2) the services supporting Enrollees with ongoing or chronic conditions are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in the State's Prepaid Mental Health Plan Waiver as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall furnish all Covered Services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to Medicaid Members under FFS, as set forth in 42 CFR § 440.230, and for Enrollees under the age of 21, as set forth in 42 CFR § 441, subpart B.
(C) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(D) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the Enrollee.
(E) The Contractor may place appropriate limits on a service on the basis of criteria applied under the State Plan such as Medical Necessity, or for the purpose of utilization control, provided:
(1) the services furnished can reasonably be expected to achieve their purpose; and
(2) the services supporting Enrollees with ongoing or chronic conditions are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports.
(F) If the Department has paid a Provider FFS for a Covered Service and later, a retroactive Capitation Payment is made to the Contractor on behalf of that Medicaid member, the Department shall retract the FFS payment for the Covered Service rendered during the retroactive period, and:
(1) the Department shall provide information to the Contractor and the Provider regarding affected Claims, and shall inform the Provider that they should obtain reimbursement from the Contractor;
(2) the Contractor shall pay Claims submitted by the Provider to the Contractor for the same amount the Department paid (unless the Provider bills the Contractor a lesser amount); and
(3) the Contractor shall not deny the Claims for timely filing if the Claim is billed to the Contractor within the federal timely filing timeframe, or require a Service Authorization Request.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in the State’s Prepaid Mental Health Plan Waiver as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall ensure that all Covered Services are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under Fee-For-Service Medicaid (set forth in 42 CFR 440.230).
(C) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(D) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary.
(E) The Contractor may place appropriate limits on a service on the basis of criteria applied under the State Plan such as Medical Necessity, or for the purpose of utilization control, provided the services furnished can reasonably be expected to achieve their purpose.
Basic Standards. The basic standard with which the above variables are measured shall be actual contact hours, whether spent in lecture, laboratory, counseling or learning resources assignment.
Basic Standards. This Agreement contains the basic standards of employment. Hospital may reward an individual employee's performance, or pay a classification or step(s) thereof, over and above the prescribed standards called for in this Agreement. Hospital will give Union notice and an opportunity for discussion before implementing any reward or change under this section.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in Attachment C and Attachment D as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall ensure that all Covered Services are furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under Fee-For-Service Medicaid, set forth in 42 CFR 440.230, and for Enrollees under the age of 21, as set forth 42 CFR 440 Subpart B.
(C) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(D) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary.
(E) The Contractor may place appropriate limits on a service on the basis of criteria applied under a State Plan such as Medical Necessity, or for the purpose of utilization control, provided:
(1) the services furnished can reasonably be expected to achieve their purpose; and
(2) the services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports;
(3) family planning services are provided in a manner that protects and enables an Enrollee’s freedom to choose the method of family planning to be used.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in Attachment C as promptly and continuously as is consistent with generally accepted standards of medical practice.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in Attachment C and Attachment D as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(C) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the Enrollee.
(D) The Contractor may place limits on a service for the purpose of utilization control, provided:
(1) the services furnished can reasonably be expected to achieve their purpose; and
(2) the services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports;
(3) family planning services are provided in a manner that protects and enables an Enrollee’s freedom to choose the method of family planning to be used.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in Attachment C as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(C) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the Enrollee.
(D) The Contractor may place appropriate limits on a service on the basis of criteria applied under a State Plan such as Medical Necessity, or for the purpose of utilization control, provided:
(1) the services furnished can reasonably be expected to achieve their purpose; and
(2) the services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports;
(3) family planning services are provided in a manner that protects and enables an Enrollee’s freedom to choose the method of family planning to be used.
Basic Standards. (A) The Contractor shall provide to Enrollees, directly or through arrangements with Providers, all Medically Necessary Covered Services described in Attachment C as promptly and continuously as is consistent with generally accepted standards of medical practice.
(B) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.
(C) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary.
