Benefits and Care Management Sample Clauses

Benefits and Care Management a. Institute of Mental Disease (IMD) Report Alternate-week report providing the prior two calendar weeks’ summary of members who are receiving SUD services in an IMD, including name, Medicaid ID number, DOB, eligibility category, SUD diagnosis, provider name, provide NPI, facility admission date and facility discharge date.
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Benefits and Care Management. Second Revised and Restated Section V.C. Table 1: Summary of Medicaid and NC Health Choice Covered Services, is revised and restated in its entirety as Third Revised and Restated Section V.C. Table 1: Summary of Medicaid and NC Health Choice Covered Services and attached to this Amendment as Attachment 1.
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Benefits and Care Management. 1. Medical and Behavioral Health Benefits, k. Electronic Visit Verification, iv. is revised and restated as follows:
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Benefits and Care Management. The Contractor shall complete a Comprehensive Needs Assessment on high- risk enrollees within thirty (30) Calendar Days after engagement. Engagement in care management is defined as receiving patient consent for care management services. If an enrollee rescinds their consent for care management or the assessment before it is due, the Contractor will not be subject to liquidated damages. The number of State Business Days the Comprehensive Needs Assessment is completed beyond the timeframe established within the Performance Standard. Quarterly For CNAs not completed in thirty (30) Calendar Days but completed in sixty (60) Calendar Days or less, there will be no liquidated damages, but there may be a CAP to improve the process. For CNAs more than sixty (60) Calendar Days late, one hundred dollars ($100) per day beyond 0 days. Up to a maximum of one thousand dollars ($1,000) per CNA. PCCM Service Level Agreements, Performance Standards and Liquidated Damages Measure Performance Standard Definition or Description of How Measured Measurement Unit or Reporting Period Liquidated Damage
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Benefits and Care Management. 1. Medical Prior Authorization Extract* Weekly extract providing information on behavioral health prior approval requests by individual Member, service type, determination date, and approval status. *For BH prior authorization requests only Weekly
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Benefits and Care Management. 4. Care Management for Children in Xxxxxx Care. a. is amended and restated as follows:
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Benefits and Care Management. 1. Medical and Behavioral Health Benefits Package, e. Utilization Management, ii. is revised and restated as follows:
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Related to Benefits and Care Management

  • IN EMPLOYMENT, SERVICES, BENEFITS AND FACILITIES Contractor and any subcontractors shall comply with all applicable federal, state, and local Anti-discrimination laws, regulations, and ordinances and shall not unlawfully discriminate, deny family care leave, harass, or allow harassment against any employee, applicant for employment, employee or agent of County, or recipient of services contemplated to be provided or provided under this Agreement, because of race, ancestry, marital status, color, religious creed, political belief, national origin, ethnic group identification, sex, sexual orientation, age (over 40), medical condition (including HIV and AIDS), or physical or mental disability. Contractor shall ensure that the evaluation and treatment of its employees and applicants for employment, the treatment of County employees and agents, and recipients of services are free from such discrimination and harassment. Contractor represents that it is in compliance with and agrees that it will continue to comply with the Americans with Disabilities Act of 1990 (42 U.S.C. § 12101 et seq.), the Fair Employment and Housing Act (Government Code §§ 12900 et seq.), and ensure a workplace free of sexual harassment pursuant to Government Code 12950 and regulations and guidelines issued pursuant thereto. Contractor agrees to compile data, maintain records and submit reports to permit effective enforcement of all applicable antidiscrimination laws and this provision. Contractor shall include this nondiscrimination provision in all subcontracts related to this Agreement and when applicable give notice of these obligations to labor organizations with which they have Agreements.

  • Covered Benefits and Services The Contractor shall provide to its Hoosier Healthwise members, at a minimum, all benefits and services deemed “medically reasonable and necessary” and covered by the IHCP, and included in the Indiana Administrative Code and under the Contract with the State. A covered service is considered medically necessary if it meets the definition as set forth in 405 IAC 5-2-17. The Contractor shall deliver covered services sufficient in amount, duration or scope to reasonably expect that provision of such services would achieve the purpose of the furnished services. Costs for these services are the basis of the Contractor’s capitation rate and are, therefore, the responsibility of the Contractor. Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with CFR 438.210(a)(4), which specifies when Contractors may place appropriate limits on services:  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 are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished.

  • Health Care Benefits (a) Each regular full-time employee may elect coverage for himself and his eligible dependents* under one of the following health insurance plans:

  • EMPLOYEE HEALTH CARE 233. Pursuant to the Charter, the City contributes whatever rate is applicable per month directly into the City Health Service System for each employee who is a member of the Health Service System. Subsequent City contributions will be set pursuant to the Charter.

  • Job Benefits and Protection The District shall insure the following provisions:

  • Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s

  • Health Care Operations Health Care Operations shall have the meaning set out in its definition at 45 C.F.R. § 164.501, as such provision is currently drafted and as it is subsequently updated, amended or revised.

  • Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

  • Emergency Care Services If you experience a medical emergency while traveling outside our service area, go to the nearest emergency or urgent care facility. When you receive Out-of-Area covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for the Out-of-Area Covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of: • the billed charges for your Out-of-Area covered healthcare services; or • the negotiated price that the Host Blue makes available to us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.

  • Dental Care Benefits (a) The Employer shall provide such regular, full-time seniority employee (and her eligible dependents*) the 100/75/50 Co-Pay Dental Plan in effect January 1, 2014, subject to such terms, conditions, exclusions, limitations, deductibles, co-payments and other provisions of the plan. The Employer shall pay 95% of the illustrated premium cost of such benefits and the employee shall pay the balance. Coverage shall commence on the day following the employee's ninetieth (90th) day of continuous employment.

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