BLUE CROSS SERVICES AND RESPONSIBILITIES Clause Samples
BLUE CROSS SERVICES AND RESPONSIBILITIES. BLUE CROSS agrees:
5.01 To perform, or arrange for the performance of, all necessary accounting and enrollment functions with respect to marketing and administering the CALIFORNIACARE program, and to issue an identification card to each Subscriber or to each Subscriber and one additional eligible Member covered under a two-party or family contract as described in the Operations Manual.
5.02 To provide PARTICIPATING MEDICAL GROUP with Member Eligibility Reports, as set forth in Article VI.
5.03 That, to the extent compatible with its obligations to BLUE CROSS hereunder, PARTICIPATING MEDICAL GROUP reserves the right to provide professional services to persons who are not Members.
5.04 To provide PARTICIPATING MEDICAL GROUP with claims paid and Non-Capitated Services data as described in the Operations Manual.
5.05 To make trained personnel available to PARTICIPATING MEDICAL GROUP to assist in Quality Management activities, the establishment of procedures for pre-admission medical review and concurrent medical review of Members who require, or may require, hospitalization.
5.06 To notify PARTICIPATING MEDICAL GROUP of any CALIFORNIACARE Group Benefit Agreements between BLUE CROSS and employers, government agencies, or any other groups, which may substantially affect enrollment at PARTICIPATING MEDICAL GROUP.
5.07 To undertake reasonable efforts, in accordance with a standard of good faith, to assure that Members assigned to PARTICIPATING MEDICAL GROUP will live or work within the Service Area defined in this Agreement. However, BLUE CROSS reserves the right to assign any Members to PARTICIPATING MEDICAL GROUP at the Member’s open enrollment period, or when the Member changes residence, or when BLUE CROSS determines such transfer to be in the Member’s best interest due to special circumstances under the terms of the Member’s Benefit Agreement.
5.08 To exercise reasonable efforts to negotiate special rates with hospitals and other providers who contract with BLUE CROSS to render Non-Capitated Services to Members and to pay hospitals in accord with those agreements.
5.09 To notify and consult with PARTICIPATING MEDICAL GROUP with respect to the development of any material changes, as determined by BLUE CROSS, or amendments to the Benefit Agreements, and to obtain PARTICIPATING MEDICAL GROUP’s consent to changes that BLUE CROSS believes may materially affect PARTICIPATING MEDICAL GROUP, except for changes required by law. The foregoing consent will not be unreas...
BLUE CROSS SERVICES AND RESPONSIBILITIES. 5.1 BLUE CROSS agrees to pay PRACTITIONER compensation pursuant to the provisions of Article VI and in accordance with the Rate Schedule in Exhibit B. BLUE CROSS shall not compensate PRACTITIONER for services that were not pre-authorized according to the Case Management/ Utilization Management program, where such pre-authorization is required.
5.2 BLUE CROSS agrees to grant PRACTITIONER the status of “Participating PATH2HEALTH/CMSP Practitioner to identify PRACTITIONER as a Participating PATH2HEALTH/CMSP Practitioner on informational materials to Members, and to facilitate the direction of such Members to PRACTITIONER.
5.3 BLUE CROSS agrees to provide PRACTITIONER with a list of Participating PATH2HEALTH/CMSP Practitioners, Participating PATH2HEALTH/CMSP Hospitals and other PATH2HEALTH/CMSP Participating Providers.
5.4 BLUE CROSS agrees to provide appropriate identification cards for Members.
5.5 BLUE CROSS agrees that the terms "Emergency" and "Medically Necessary" shall bear the same meanings in Benefit Agreements as in this Agreement.
5.6 BLUE CROSS agrees to continue listing PRACTITIONER as Participating PATH2HEALTH/CMSP Practitioner until this Agreement is terminated.
BLUE CROSS SERVICES AND RESPONSIBILITIES. Section 5.01 shall be deleted and Section 5.01 is hereby restated in full to read: To perform or arrange for the performance of all necessary accounting and enrollment functions with respect to marketing and administering the CALIFORNIACARE program and AIM Program and to issue a CALIFORNIACARE or an AIM identification card to each Subscriber or each Subscriber and one additional eligible Member covered under a two-party or family contract as described in the Operations Manual. However, AIM Program enrollment shall be determined by the State of California and shall be reported to PARTICIPATING MEDICAL GROUP by BLUE CROSS as directed by the State of California.