CALCULATIONS FOR OUTPATIENT SERVICES REIMBURSEMENT. MOPPS Reimbursement calculation:
CALCULATIONS FOR OUTPATIENT SERVICES REIMBURSEMENT Sample Clauses
Related to CALCULATIONS FOR OUTPATIENT SERVICES REIMBURSEMENT
Outpatient Services Physicians, Urgent Care Centers and other Outpatient Providers located outside the BlueCard® service area will typically require You to pay in full at the time of service. You must submit a Claim to obtain reimbursement for Covered Services.
Inpatient Services Hospital Rehabilitation Facility
Administrative Support Services Fees Within forty-five (45) days of the end of each calendar quarter or at such other period as deemed appropriate by the Distributor, the Fund will make payments in the aggregate amount of up to 0.25% on an annual basis of the average during the period of the aggregate net asset value of the Shares computed as of the close of each business day (the “Service Fee”). Such Service Fee payments received from the Fund will compensate the Distributor for providing administrative support services with respect to Accounts. The administrative support services in connection with Accounts may include, but shall not be limited to, the administrative support services that a Recipient may render as described in Section 3(b)(i) below.
Payments for Distribution Assistance and Administrative Support Services (a) Payments to the Distributor. In consideration of the payments made by the Fund to the Distributor under this Plan, the Distributor shall provide administrative support services and distribution services to the Fund. Such services include distribution assistance and administrative support services rendered in connection with Shares (1) sold in purchase transactions, (2) issued in exchange for shares of another investment company for which the Distributor serves as distributor or sub-distributor, or (3) issued pursuant to a plan of reorganization to which the Fund is a party. If the Board believes that the Distributor may not be rendering appropriate distribution assistance or administrative support services in connection with the sale of Shares, then the Distributor, at the request of the Board, shall provide the Board with a written report or other information to verify that the Distributor is providing appropriate services in this regard. For such services, the Fund will make the following payments to the Distributor:
Professional Services Fees You agree to pay us the professional services fees in the amounts set forth in the Investment Summary. Those amounts are payable in accordance with our Invoicing and Payment Policy. You acknowledge that the fees stated in the Investment Summary are good-faith estimates of the amount of time and materials required for your implementation. We will bill you the actual fees incurred based on the in-scope services provided to you. Any discrepancies in the total values set forth in the Investment Summary will be resolved by multiplying the applicable hourly rate by the quoted hours.
Compensation and Billing 6.1 The Facility shall only seek payment from EGID for the provision of Covered Services. The Facility agrees to accept the amount of the Allowable Fee for Covered Services as payment in full and agrees to only request payment from the Member for deductible, co-insurance and amounts for defined Non-Covered Services attributable to the Member’s Health Choice Plan. The payment shall be calculated and limited to the methodologies defined by this Contract. 6.2 When the Allowable Fee exceeds billed charges, EGID shall pay the appropriate percentage of the Allowable Fee and Member shall pay the appropriate percentage of billed charges unless the Member has met the stop loss limitation and then EGID shall pay the Allowable Fee and the Member has no liability. 6.3 When processing inpatient claims, EGID shall determine the MS-DRG Allowable Fee for non- transfer cases according to the following formula: Skilled Nursing Facility Services, Day Treatment and Residential treatment will be reimbursed utilizing the per diem methodology. In no event shall a per diem qualify as an Outlier. These benefits shall be allowed when the Member has received Medically Necessary Covered Services subject to the following policy limitations and conditions: a) EGID shall pay the appropriate percentage of the MS-DRG Allowable Fee and the Member shall pay the remainder of the MS-DRG Allowable Fee unless the Member has met the stop loss limitation, and then EGID shall pay one hundred percent (100%) of the MS-DRG Allowable Fee and the Member has no liability. b) The MS-DRG shall be controlling, subject to EGID’s approval and Article X of the Contract. c) The MS-DRG Allowable Fee does not include any physician professional component fees, which are considered for payment according to separately billed Current Procedural Terminology code Allowable Fees. d) EGID may reduce its payment by any deductibles, coinsurance and co- payments owed by the Member. e) EGID shall include the day of admission but not the day of discharge when computing the number of facility days provided to a Member. Observation Facility confinements for which a room and board charge is incurred shall be paid based on inpatient benefits. f) In the case of a transfer, the Transfer Allowable Fee for the transferring Facility shall be calculated as follows: Transfer Allowable Fee = (MS-DRG Allowable Fee/Geometric Mean Length of Stay) x (Length of Stay + 1 day) The total Transfer Allowable Fee paid to the transferring Facility shall be capped at the amount of the MS-DRG Allowable Fee for a non-transfer case. EGID shall allow payment to the receiving Facility, if it is also the final discharging Facility, at the MS- DRG Allowable Fee as if it were an original admission. g) EGID shall use the current version of the CMS MS-DRG grouper to categorize what shall constitute a procedure. XXXX’s and the Member’s financial liability shall be limited to the Allowable Fee as determined by XXXX. h) The Facility agrees not to charge more for Medical Services to Members than the amount normally charged by the Facility to other patients for similar services. i) For Outlier cases, EGID shall base its payment to the Facility using an Outlier Allowable Fee plus the MS-DRG Allowable Fee. The following formula shall be utilized to calculate the Outlier Allowable Fee: Outlier Allowable Fee = [Billed Charges – (MS-DRG Allowable Fee + Outlier Threshold)] x Marginal Cost Factor 6.4 When processing Outpatient claims, XXXX agrees to pay the Facility the Allowable Fee based on appropriate billing according to the following: a) If a procedure does not have an Allowable Fee, EGID will allow a percentage of the billed charges for Covered Services. b) EGID shall pay the appropriate percentage of the Allowable Fee and the Member shall pay the remainder based on the Member’s plan of benefits unless the Member has met the stop loss limitation, and then EGID shall pay 100% of the Allowable Fee and the Member has no liability.
Administrative Support Service Fees Within forty-five (45) days of the end of each calendar quarter, the Fund will make payments in the aggregate amount of 0.0625% (0.25% on an annual basis) of the average during that calendar quarter of the aggregate net asset value of the Shares computed as of the close of each business day (the "Service Fee"). Such Service Fee payments received from the Fund will compensate the Distributor for providing administrative support services with respect to Accounts. The administrative support services in connection with Accounts may include, but shall not be limited to, the administrative support services that a Recipient may render as described in Section 3(b)(i) below.
EFT SERVICES If approved, you may conduct any one (1) or more of the EFT services offered by the Credit Union.
Payment Services The Application allows the User to access some or all of the following Payment Services (depending on the services that the Partner has integrated). ● The opening of a Payment Account; ● Carrying out the following operations: o Withdrawal o Transfers (in/out) o Direct debits (in / out) o Payment transactions through a Card; ● Issuing of a Card, associated with the Payment Account; ● Card acquiring
Educational Reimbursement A) The City will reimburse tuition costs and general fees for courses taken at an educationally accredited college or university by full-time permanent employees. Such course work must be approved prior to enrolling by submitting documentation that the course(s) is necessary toward a degree which is required for a position in the City (including electives for that degree). Thereafter, the course work must be approved by the Department Head and finally to the Director of Human Resources. The fact that a specific course is required for a degree major where the degree with such a major exists as a minimum requirement for a higher classification will be relevant. B) The City will also reimburse for technical courses. Courses must either be directly related to the employee’s current job or related to another classification career path. The determination of relatedness shall be made by the Director of Human Resources. To be related to a career path the course work must be within three (3) normal promotional steps. Technical courses will be fully reimbursed for a passing grade. C) The City will reimburse the employee the cost of tuition and general fees for ten (10) credit hours per quarter/semester at the percentage rate of 100% for a grade of "A" "B" or "C". Reimbursement shall be limited to tuition levels and general fees charged by the University of Toledo. These costs will be reimbursed upon the documented presentation of a "C" or 2.0 grade or better. D) If licensing or certification is a requirement of a classification held by an employee, the City shall pay the employee's licensing or certification expenses. Expenses for required training and/or educational units necessary for maintaining licenses or certifications used or mandated for any classification shall also be reimbursed by the City. E) The City shall provide training and/or educational programs for full-time permanent employees to enhance career development under a program established jointly by the parties. (refer to Section 2106.72) F) The City and AFSCME Local 2058 recognize the importance of maintaining and upgrading skills as changes occur in the workplace. The parties are committed to identifying resources to assist employees with upgrading their skills. Training in these new areas may be done by City personnel. When it is beyond the scope of City personnel, training may be conducted through outside services. These costs shall be borne under the City's continuing education program. G) Any employee participating in the tuition reimbursement program that resigns, retires (non- disability) or is terminated must repay in full the tuition reimbursement paid by the City for courses completed less than five (5) years prior to the date of resignation, retirement, or termination. If necessary, this amount shall be deducted from the employee’s severance pay and/or his or her final paycheck. In the event the employee’s severance pay and/or final paycheck are insufficient to cover the full tuition reimbursement owed to the City, the employee must make arrangements to repay the amount owed. The City may pursue collection of the amount owed, if necessary. An employee who resigns or is terminated for cause or performance will lose all rights and benefits under the educational reimbursement refund policy effective on the date of his or her resignation, retirement, or termination. 2106.92 Base Annual Salaries A) Hourly Wages B) In accordance with Section 2106.02 “Classifications,” effective January 1, 2019, the Supervisor – Communications position will be divided into Supervisor - Police Communications and Supervisor - Fire Communications. The Supervisor - Fire Communications classification will be assigned to salary group eleven (11) and the Supervisor - Police Communications classification will be assigned to salary group thirteen (13). The employees will not receive another base wage increase for the duration of the agreement. CD) An employee who is promoted or who works above his classification will receive the Starting Rate of the class to which the employee has been promoted unless the Starting Rate of the new classification is less than four percent (4%) greater than the rate the employee was earning in his regular classification. If the Starting Rate of the new classification is not at least four percent (4%) greater than the rate the employee was earning in his regular classification, then the employee shall receive the full rate of the new classification. When an employee falls into a pay status that reflects less than one (1) cent, between the start rate and the full rate, then the City shall pay the full rate of pay. The Mayor may decide to pay a promoted employee at the full rate of pay that is applicable, provided that such decisions shall not establish a precedent or practice. Promoted employees at the Starting Rate will remain at the rate for one thousand forty (1,040) actual work hours after their appointment.
