Capitated Professional Services Clause Samples
The Capitated Professional Services clause establishes a payment arrangement where a healthcare provider receives a fixed, predetermined amount per patient for delivering a defined set of professional medical services over a specified period, regardless of how many services each patient actually uses. In practice, this means the provider is paid the same monthly or annual fee for each enrolled patient, covering all agreed-upon services such as office visits, consultations, and routine care. This clause helps control healthcare costs and incentivizes providers to manage resources efficiently, as it shifts some financial risk from the payer to the provider and discourages unnecessary services.
Capitated Professional Services. Group shall provide or arrange for the provision of all Medically Necessary Capitated Professional Services to Members and shall be fully financially responsible for same. Such services shall be provided through Group Providers who have been credentialed as required by this Agreement and as more fully described in the Provider Manual. Without limiting the foregoing, Group shall: (i) be financially responsible for Emergency and Urgent Care Services provided by healthcare providers in addition to Group Providers, as set forth in Exhibit B., (ii) refer Members, at Group’s cost and when Group Providers are not available to provide Medically Necessary Capitated Services, to non-Group Providers; (iii) provide all preventive health services to which a Member is entitled under his/her Benefit Plan; and, (iv) make available to Members those health education programs routinely provided by Group and Group Providers at no charge to their patients.
Capitated Professional Services are those Covered Services which are described in Exhibit B. hereto as the financial responsibility of Group. Capitated Professional Services also include any Covered Services which are not listed in Exhibit B., but which are customarily provided by IPAs, Medical Groups to their patients. Blue Shield may periodically amend Capitated Professional Services to include any additional physician and/or ancillary services which must be provided by law.