Contracted Providers. In some cases, an out-of-network provider may have a contract with us, but is not part of your network. Even though your bills will be reimbursed at the lower percentage (the out-of-network benefit level), contracted providers will not bill you for the amount above the allowed amount for a covered service. Non-contracted providers. Out-of-network non-contracted providers do not have a contract with us or with any of the other networks used by this plan. These providers will bill you the amount above the allowed amount for a covered service. The following covered services and supplies provided by out-of-network providers will always be covered at the in-network level of benefits (based on the out-of-network allowed amount): Emergency care for a medical emergency. (Please see the "Definitions" section for definitions of these terms.) This plan provides worldwide coverage for emergency care. The benefits of this plan will be provided for covered emergency care without the need for any prior authorization and without regard as to whether the health care provider furnishing the services is a network provider. Emergency care furnished by an out-of-network provider will be reimbursed on the same basis as a network provider. As explained above, if you see an out-of-network provider, you may be responsible for amounts that exceed the allowed amount. Services from certain categories of providers to which provider contracts are not offered. These types of providers are generally not listed in the provider directory. Services associated with admission by an in-network provider to an in-network hospital that are provided by hospital-based providers. Facility and hospital-based provider services received in Washington from a hospital that has a provider contract with us, if you were admitted to that hospital by an in-network provider who doesn’t have admitting privileges at an in-network hospital. Covered services received from providers located outside the United States. If a covered service is not available from an in-network provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. However, you must request this before you get the care. See Prior Authorization for details.
Contracted Providers. Provider shall, and shall cause each Contracted Provider, to comply with and abide by the agreements, representations, warranties, acknowledgements, certifications, terms and conditions of this Agreement (including the provisions of Schedule A that are applicable to Provider, a Contracted Provider, or their services, and any other Attachments), and the Provider Manual, and fulfill all of the duties, responsibilities and obligations imposed on Provider and Contracted Providers under this Agreement (including each Attachment), and the Provider Manual, in each case, to the same extent as if the Contracted Providers were parties hereto. Provider shall be responsible for any breach of this Agreement by any Contracted Provider.
Contracted Providers. Each Loan Party and their Subsidiaries is in material compliance with all applicable material Health Care Laws regarding the selection, deselection, and credentialing of contracted providers, including, but not limited to, verification of licensing status and eligibility for reimbursement under the Third Party Payor Programs. All contracted providers of each Loan Party and their Subsidiaries are properly licensed and hold appropriate Permits and clinical privileges, as applicable, for the professional services which they provide, and, with respect to providers that perform services eligible for reimbursement under any Third Party Payor Program, are not debarred or excluded from any such Third Party Payor Program.
Contracted Providers. Except as would not reasonably be expected to result in a Material Adverse Effect, each Loan Party and their Subsidiaries is in material compliance with all applicable material Health Care Laws regarding the selection, deselection, and credentialing of contracted providers, including, but not limited to, verification of licensing status and eligibility for reimbursement under the Third Party Payor Programs. Except as would not reasonably be expected to result in a Material Adverse Effect, all contracted providers of each Loan Party and their Subsidiaries are properly licensed and hold appropriate Permits and clinical privileges, as applicable, for the professional services which they provide, and, with respect to providers that perform services eligible for reimbursement under any Third Party Payor Program, are not debarred or excluded from any such Third Party Payor Program.
Contracted Providers. Before Health Plan can deny a referral to a non-Participating Provider, the request must be reviewed by a specialist similar to the type of specialist to whom a referral is requested.
Contracted Providers. Except in the case of Emergency Services or upon prior authorization of Health Plan, Provider shall use only those health professionals, hospitals, laboratories, skilled nursing and other facilities and providers which have contracted with Health Plan (“participating providers”).
Contracted Providers. 2 1.3 Fees, Charges and Payor Agreements....................... 2 1.4
Contracted Providers. Except in the case of Emergency Services or upon prior authorization of Health Plan, Provider shall use only those health professionals, hospitals, laboratories, skilled nursing and other facilities and providers which have contracted with Health Plan (“Participating Providers”). Molina ECMS ref# 729 Provider or authorized MHC v122706 / MHI v091707 representative’s initials: Pacific Hospital of Long Beach
Contracted Providers. If you think this sounds like it is an important forum for which you should have strong representation (it directly impacts your contracted business) - we agree - and this briefing provides further information on how PSAAP (We pronounce it "pea-sap"!) works. PSAAP has traditionally met in-person in Wellington every 2-3 months. More recently this has often occurred virtually. There can typically be any number of attendees between around 20 and sometimes up to 40 or 50. The attendees tend to be:
1. Two Ministry of Health lead representatives - usually including one Deputy Director General - plus any number of primary care policy and strategy officials.
2. Two DHB lead representatives - usually Xx Xxxx Xxxxxxxxxxx (CEO of Northland DHB) and Xxxxxxx Xxxxxxxx (CEO of Hawke’s Bay DHB) - plus any number of planning and funding or primary care managers from other DHBs (each DHB has the ability to appoint its own agent at PSAAP)
3. Four PHO lead representatives - usually from General Practice New Zealand (GPNZ), National Hauora Coalition and two others - plus many additional PHO Chief Executives/managers (each PHO has the ability to appoint its own agent at PSAAP)
4. Two lead representatives for Contracted Providers (General Practice owners) - these are now appointed by the Contracted Provider Caucus (linked to the General Practice Leaders Forum/GPLF) and are currently Dr Xxxx Xxxxxxxx and Xx Xxxxx Xxxxxxxx. An agenda and papers are circulated for each meeting. Whilst the timing and availability of papers are referenced in the [Protocol], papers are often submitted outside of the specified timescales. Each meeting of PSAAP tends to be preceded by a meeting of the Primary Care Caucus - which is a separate forum through which PHO representatives and Contracted Provider representatives review the agenda and papers and seek consensus on the matters scheduled for discussion/negotiation.
Contracted Providers. Professional Association shall have complete control of and responsibility for the hiring, engagement, compensation, supervision, evaluation, and termination of all Contracted Providers who will provide patient care services, although at the request of Professional Association, Management Company shall consult with Professional Association respecting such matters. With respect to physicians, Professional Association shall only contract with licensed physicians meeting applicable credentialling guidelines established by Professional Association. Professional Association may enter into employment agreements with Physician Assistants licensed to practice in the State of Texas to perform services for Patients. Professional Association shall be responsible for the payment of salaries and wages, compensation, payroll taxes, employee benefits, and all other taxes and charges now or hereafter applicable to Contracted Providers and Physician Assistant employees, all of which shall be in conformity with the applicable Professional Association Budget described in Section 2.4(a). A list of all Contracted Providers and Physician Assistant employees is set forth at SCHEDULE 1.2, attached hereto and incorporated herein by reference. Prior to making any changes to the list of Contracted Providers, or licensed or health care professional employees set forth at SCHEDULE 1.2, Professional Association shall consult with Management Company. Professional Association shall also consult with Management Company with regard to the terms of contracts entered into between Professional Association and Contracted Providers, or licensed Physician Assistant employees, and the terms and conditions of their employment or engagement as independent contractors, as applicable.
