Decision Making for Healthcare
Decision Making for Healthcare Sample Clauses
Related to Decision Making for Healthcare
COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.
Extended Health Care Plan (a) The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable Extended Health Care Plan.
Clinical Management for Behavioral Health Services (CMBHS) System The CMBHS is the official record of documentation by System Agency. Grantee shall:
Outpatient emergency and urgicenter services within the service area The emergency room copay applies to all outpatient emergency visits that do not result in hospital admission within twenty-four (24) hours. The urgicenter copay is the same as the primary care clinic office visit copay.
NYS OFFICE OF INFORMATION TECHNOLOGY SERVICES NOTIFICATION All New York State Agencies must notify the Office of Information Technology Services of any and all plans to procure IT and IT -related products, materials and services meeting required thresholds defined in Technology Policy NYS–P08-001: xxxxx://xxx.xx.xxx/sites/default/files/documents/NYS-P08-001.pdf, as may be amended, modified or superseded. SALES REPORTING REQUIREMENTS Contractor shall furnish OGS with quarterly sales reports utilizing Appendix I - Report of Contract Sales. Purchases by Non- State Agencies, political subdivisions and others authorized by law shall be reported in the same report and indicated as required. All fields of information shall be accurate and complete. OGS reserves the right to unilaterally make revisions, changes and/or updates to Appendix I - Report of Contract Sales or to require sales to be reported in a different format without processing a formal amendment and/or modification. Further, additional related sales information and/or detailed Authorized User purchases may be required by OGS and must be supplied upon request. Reseller Sales Product sold through Reseller(s) must be reported by Contractor in the required Appendix I – Report of Contract Sales. Due Date The Appendix I - Report of Contract Sales will be quarterly (January - March, April - June, July - September and October - December). Reports will be due 1 month after the closing quarter. SERVICE REPORTS FOR MAINTENANCE/SUPPORT AND WARRANTY WORK Service Reports for Authorized User An Authorized User in an RFQ may require compliance with any or all of this section. If requested by the Authorized User, the Contractor shall furnish the Authorized User with service reports for all Maintenance/support and warranty work upon completion of the services. The service reports may include the following information in either electronic or hard copy form as designated by the Authorized User: Date and time Contractor was notified Date and time of Contractor’s arrival Make and model of the Product Description of malfunction reported by Authorized User Diagnosis of failure and/or work performed by Contractor Date and time failure was corrected by Contractor Type of service – Maintenance/support or warranty Charges, if any, for the service Service Reports for OGS
Health Services At the time of employment and subject to (b) above, full credit for registered professional nursing experience in a school program shall be given. Full credit for registered professional nursing experience may be given, subject to approval by the Human Resources Division. Non-degree nurses shall be placed on the BA Track of the Teachers Salary Schedule and shall be ineligible for movement to any other track.
Allocation and use of scarce resources Any procedures for the allocation and use of scarce resources, including frequencies, numbers and rights of way, will be carried out in an objective, timely, transparent and non-discriminatory manner. The current state of allocated frequency bands will be made publicly available, but detailed identification of frequencies allocated for specific government uses is not required.
Branding for Operator Call Processing and Directory Assistance 8.4.1 BellSouth's branding feature provides a definable announcement to Telepak Networks end users using Directory Assistance (DA)/ Operator Call Processing (OCP) prior to placing such end users in queue or connecting them to an available operator or automated operator system. This feature allows Telepak Networks’ name on whose behalf BellSouth is providing Directory Assistance and/or Operator Call Processing. Rates for the branding features are set forth in Exhibit D.
Mental Health Services This agreement covers medically necessary services for the treatment of mental health disorders in a general or specialty hospital or outpatient facilities that are: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a general or specialty hospital or outpatient facility. We review network and non-network programs, hospitals and inpatient facilities, and the specific services provided to decide whether a preauthorization, hospital or inpatient facility, or specific services rendered meets our program requirements, content and criteria. If our program content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below.
