Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.
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.
Core Services The Company agrees to provide those Core Services to the Municipality as set forth in Schedule “A” and further agrees to the process contained in Schedule “A”.
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
Acupuncture Services Benefits will be provided for Medically Necessary acupuncture services when provided by a provider licensed to perform such services.
Free Services MIRAGE may make Free Services available to You. Use of Free Services is subject to the terms and conditions of this Agreement. In the event of a conflict between this Section 2.2 (Free Services) and any other portion of this Agreement, this section shall control. Please note that Free Services are provided to you without charge up to certain limits as described in the Documentation. Usage over these limits requires your purchase of additional resources or services. You agree that MIRAGE, in its sole discretion and for any or no reason, may terminate your access to the Free Services or any part thereof. You agree that any termination of your access to the Free Services may be without prior notice, and you agree that MIRAGE will not be liable to you or any third party for such termination. You are solely responsible for exporting Your Data from the Free Services prior to termination of Your access to the Free Services for any reason, provided that if We terminate your account, except as required by law We will provide you a reasonable opportunity to retrieve Your Data. NOTWITHSTANDING SECTION 9 (REPRESENTATIONS, WARRANTIES, EXCLUSIVE REMEDIES AND DISCLAIMERS), THE FREE SERVICES ARE PROVIDED “AS-IS” WITHOUT ANY WARRANTY. WITHOUT LIMITING THE FOREGOING, MIRAGE AND ITS AFFILIATES AND ITS LICENSORS DO NOT REPRESENT OR WARRANT TO YOU THAT: (A) YOUR USE OF THE FREE SERVICES WILL MEET YOUR REQUIREMENTS,
Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:
Career Services Placement assistance is not provided. It is understood that the School does not and cannot promise or guarantee neither employment nor level of income or wage rate to any Student or Graduate.
Career Ladder Effective July 1, 2014, TALC and the District agreed to the 11 implementation of a Career Ladder for the advancement of instructional staff on the 12 Performance Salary Schedule. Elements of the Career Ladder are outlined and posted on 13 the District website and include detailed descriptions of Career Ladder levels and the 14 requirements for movement. All instructional staff hired on or after January 8, 2018 will 15 be placed on the Apprentice level of the Career Ladder.
