Disenrollment Initiated by the Contractor Sample Clauses

Disenrollment Initiated by the Contractor. The Contractor may not request disenrollment of an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from special needs (except when continued enrollment in the PMHP seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees).
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Disenrollment Initiated by the Contractor. 4.2.2.1 The Contractor shall complete all Disenrollment paperwork for Members it is seeking to disenroll. 4.2.2.2 The Contractor shall notify DCH or its Agent upon identification of a Member who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.1. 4.2.2.3 Prior to requesting Disenrollment of a Member for reasons described in Sections 4.2.3.1.1, 4.2.3.1.2, and 4.
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Disenrollment Initiated by the Contractor. 5.4.4.1 The Contractor shall complete all paperwork required by ASES for the Disenrollment of Enrollees it is seeking to disenroll. 5.4.4.2 ASES reserves authority to make all Disenrollment decisions; nonetheless, the Contractor shall issue the notice of Disenrollment to the Enrollee (see Section 5.4.2 of this Contract). 5.4.4.3 The Contractor has a limited right to request that an Enrollee be disenrolled without the Enrollee’s consent. The Contractor shall notify ASES upon identification of an Enrollee who it knows or believes meets the criteria for Disenrollment. 5.4.4.4 When requesting Disenrollment of an Enrollee for reasons described in Section 5.4.4.7 of this Contract, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and care coordination to resolve any difficulty leading to the request. The Contractor shall also provide evidence of having given at least one (1) written warning to the Enrollee, certified return receipt requested, regarding implications of his or her actions. 5.4.4.5 If the Enrollee has demonstrated abusive or threatening behavior as defined by ASES, only one (1) Contractor intervention, and a subsequent written attempt to resolve the difficulty, are required. 5.4.4.6 The Contractor shall submit Disenrollment requests to ASES, and the Contractor shall honor all Disenrollment determinations made by ASES. ASES’s decision on the matter shall be final, conclusive and not subject to appeal by the Contractor. 5.4.4.7 The following are acceptable reasons for the Contractor to request Disenrollment: 5.4.4.7.1 The Enrollee’s continued Enrollment in the MiSalud Plan seriously impairs the ability to furnish services to either this particular Enrollee or other Enrollees; 5.4.4.7.2 The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness; 5.4.4.7.3 The Enrollee’s use of services constitutes Fraud or Abuse (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services); 5.4.4.7.4 The Enrollee has moved out of Puerto Rico or out of the Contractor’s Service Regions; 5.4.4.7.5 The Enrollee is placed in a long-term care nursing facility or intermediate care facility for the mentally retarded; 5.4.4.7.6 The Enrollee’s Medicaid or CHIP eligibility category changes to a category ineligible for MiSalud; or 5.4.4.7.7 The ...
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Disenrollment Initiated by the Contractor. 4.2.2.1 The Contractor shall complete all Disenrollment paperwork for Members or P4HB Participants it is seeking to disenroll. 4.2.2.1.1 The Contractor shall complete all Disenrollment paperwork for any P4HB Participants it seeks to disenroll. 4.2.2.2 The Contractor shall notify DCH or its Agent upon identification of a Member or P4HB Participant who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3. 4.2.2.2.1 The Contractor shall notify DCH or its Agent upon identification of a P4HB Participant who it knows or believes meets the following criteria for disenrollment from the Demonstration: • The P4HB Participant no longer meets the eligibility criteria for the Demonstration. • The IPC P4HB Participant has reached the end of the twenty-four (24) months of eligibility for the IPC component of the Demonstration. • The P4HB Participant becomes pregnant while enrolled in the Demonstration; • The P4HB Participant becomes infertile through a sterilization procedure; • The P4HB Participant moves out of the CMO plan’s Service Region; • The P4HB Participant’s utilization of services is fraudulent or abusive; • The Participant’s eligibility category changes to a category ineligible for participation in the P4HB program; • The P4HB Participant has died, been incarcerated, or moved out of State, thereby making her ineligible for Medicaid. 4.2.2.3 Prior to requesting Disenrollment of a Member or P4HB Participant for reasons described in Sections 4.2.3, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member or P4HB Participant, certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be delivered within ten (10) Business Days of the Member’s or P4HB Participants action. 4.2.2.4 The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member or P4HB Participant. 4.2.2.5 The Contractor shall submit Disenrollment requests to DCH or its Agent and the Contractor shall honor all Disenrollment determinations made by DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and not subject to appeal.
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Disenrollment Initiated by the Contractor. (A) The Contractor may not terminate an Enrollee’s enrollment because of an adverse change in the Enrollee’s health or because of the Enrollee’s utilization of Covered Services. (B) The Contractor may initiate disenrollment of any Enrollee for one or more of the following reasons: (1) For reasons specifically identified in the Contractor’s approved Enrollee handbook; (2) When the Enrollee ceases to be eligible for medical assistance under the State’s Title XXI State Plan and as finally determined by the Department; (3) Upon expiration of the Contractor’s Contract with the Department; (4) Confinement of an Enrollee in an institution when confinement is not a Covered Service under this contract; (5) Violation of enrollment requirements developed by the Contractor and approved by the Department but only after the Contractor and/or the Enrollee has exhausted the Contractor’s applicable internal Grievance procedure; or (6) When the Contractor has determined that the Enrollee has other valid health insurance coverage. (C) To initiate disenrollment of an Enrollee’s participation in the Contractor’s Dental Plan, the Contractor shall provide the Department with documentation justifying the proposed disenrollment. (1) The Department shall approve or deny the disenrollment request by email or in writing within thirty days of receipt of the request. Failure by the Department to deny a disenrollment request within thirty days shall constitute an approval of the Contractor’s disenrollment request. (2) If the Department approves the Contractor’s disenrollment request, the Contractor shall give the Enrollee thirty days written notice of the proposed disenrollment, and shall notify the Enrollee of his or her right to file a
Sample 1
Disenrollment Initiated by the Contractor. 4.2.2.1 The Contractor shall complete all Disenrollment paperwork for Members it is seeking to disenroll. 4.2.2.2 The Contractor shall notify DCH or its Agent upon identification of a Member who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3. 4.2.2.3 Prior to requesting Disenrollment of a Member for reasons described in Sections 4.2.3, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member, certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be delivered within ten (10) Business Days of the Member’s action. 4.2.2.4 The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member. 4.2.2.5 The Contractor shall submit Disenrollment requests to DCH or its Agent and the Contractor shall honor all Disenrollment determinations made by DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and not subject to appeal.
Sample 1
Disenrollment Initiated by the Contractor. The Contractor has a limited right to request that an Enrollee be disenrolled without the Enrollee’s consent. The Contractor shall notify ASES upon identification of an Enrollee who it knows or believes meets the criteria for Disenrollment. The Contractor shall submit Disenrollment requests to ASES, and the Contractor shall honor all Disenrollment determinations made by ASES. XXXX’s decision on the matter shall be final, conclusive, and not subject to appeal by the Contractor. The following are acceptable reasons for the Contractor to request Disenrollment: The Enrollee’s continued Enrollment in the Contractor’s Plan seriously impairs the ability to furnish services to either this particular Enrollee or other Enrollees; The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness; The Enrollee’s use of services is fraudulent or abusive (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services); The Enrollee is placed in a long-term care nursing facility or intermediate care facility for the intellectually disabled; The Enrollee’s Medicaid or CHIP eligibility category changes to a category ineligible for the GHP; or The Enrollee has died or moved out of Puerto Rico, thereby making him or her ineligible for Medicaid or CHIP or is otherwise ineligible for the GHP. ASES will approve a Disenrollment request by the Contractor, in ASES’s discretion, only if ASES determines: That it is impossible for the Contractor to continue to provide services to the Enrollee without endangering the Enrollee or other GHP Enrollees; and That an action short of Disenrollment, such as transferring the Enrollee to a different PCP or PMG, will not resolve the problem. The Contractor may not request Disenrollment for any discriminatory reason including, but not limited, to the following: Adverse changes in an Enrollee’s health status; Missed appointments; Utilization of medical services; Diminished mental capacity; Pre-existing medical condition; The Enrollee’s attempt to exercise his or her rights under the Grievance and Appeal System; or Uncooperative or disruptive behavior resulting from the Enrollee’s special needs. The request of one (1) PMG to have an Enrollee assigned to a different PMG, per Section 5.4, shall not be sufficient cause for the Contractor to request that the Enrollee be disenrolled from the Plan. Rather, the Contractor shall, if po...
Sample 1
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Disenrollment Initiated by the Contractor. 5.4.4.1 The Contractor shall complete all paperwork required by ASES for the Disenrollment of Enrollees it is seeking to disenroll. 5.4.4.2 ASES reserves authority to make all Disenrollment decisions; nonetheless, the Contractor shall issue the notice of Disenrollment to the Enrollee (see Section 5.4.2). 5.4.4.3 The Contractor has a limited right to request that an Enrollee be disenrolled without the Enrollee's consent. The Contractor shall notify ASES upon identification of an Enrollee who it knows or believes meets the criteria for Disenrollment. When requesting Disenrollment of an Enrollee for reasons described in Section 5.4.4.7, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and care coordination to resolve any difficulty leading to the request. The Contractor shall also provide evidence of having given at least one (1) written warning to the Enrollee, certified return receipt requested, regarding implications of his or her actions.
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Related to Disenrollment Initiated by the Contractor

  • Disenrollment An Enrollee must be disenrolled from the Plan if the Beneficiary: a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor must notify the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writing. The effective date of any approved disenrollment will be no later than the first day of the second month following the month in which the Enrollee or the Plan files the request with the Division.

  • initiated by ICANN Upon reaching 10% of the Emergency thresholds as described in Section 6 of this Specification, ICANN’s emergency operations will initiate an Emergency Escalation with the relevant Registry Operator. An Emergency Escalation consists of the following minimum elements: electronic (i.e., email or SMS) and/or voice contact notification to the Registry Operator’s emergency operations department with detailed information concerning the issue being escalated, including evidence of monitoring failures, cooperative trouble-shooting of the monitoring failure between ICANN staff and the Registry Operator, and the commitment to begin the process of rectifying issues with either the monitoring service or the service being monitoring.

  • Contractor Certification for Contractor Employees Introduction Texas Education Code Chapter 22 requires entities that contract with school districts to provide services to obtain criminal history record information regarding covered employees. Contractors must certify to the district that they have complied. Covered employees with disqualifying criminal histories are prohibited from serving at a school district. Definitions: Covered employees: Employees of a contractor or subcontractor who have or will have continuing duties related to the service to be performed at the District and have or will have direct contact with students. The District will be the final arbiter of what constitutes direct contact with students. Disqualifying criminal history: Any conviction or other criminal history information designated by the District, or one of the following offenses, if at the time of the offense, the victim was under 18 or enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an offense for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal Procedure; or (c) an equivalent offense under federal law or the laws of another state. I certify that: NONE (Section A) of the employees of Contractor and any subcontractors are covered employees, as defined above. If this box is checked, I further certify that Contractor has taken precautions or imposed conditions to ensure that the employees of Contractor and any subcontractor will not become covered employees. Contractor will maintain these precautions or conditions throughout the time the contracted services are provided. OR SOME (Section B) or all of the employees of Contractor and any subcontractor are covered employees. If this box is checked, I further certify that: (1) Contractor has obtained all required criminal history record information regarding its covered employees. None of the covered employees has a disqualifying criminal history.

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Emergency Escalation initiated by ICANN Upon reaching 10% of the Emergency thresholds as described in Section 6 of this Specification, ICANN’s emergency operations will initiate an Emergency Escalation with the relevant Registry Operator. An Emergency Escalation consists of the following minimum elements: electronic (i.e., email or SMS) and/or voice contact notification to the Registry Operator’s emergency operations department with detailed information concerning the issue being escalated, including evidence of monitoring failures, cooperative trouble-­‐shooting of the monitoring failure between ICANN staff and the Registry Operator, and the commitment to begin the process of rectifying issues with either the monitoring service or the service being monitoring.

  • Enrollment The Competitive Supplier shall be responsible for enrolling all Eligible Consumers through EDI transactions submitted to the LDC for all enrollments of Eligible Consumers during the term of this Agreement.

  • TRIAL SERVICE Section 1. Each employee appointed to a position in the bargaining unit shall serve a trial service period upon: • initial appointment to state service; • promotion; • lateral transfer inside his/her Agency to a different classification; • lateral transfer between agencies; • or rehire within two (2) years of separation (including reemployment). Section 2. The trial service period is recognized as an extension of the selection process and is the time immediately following appointment and shall not exceed six (6) full months. For part-time employees trial service shall be 1,040 hours. Trial service will be nine (9) months for employees hired in the classification of Child Support Case Manager (Entry) in DOJ; Client Care Surveyor and Disability Analyst (Entry). Trial service will be twelve (12) months for new employees hired as Industrial Hygienist 1 and 2, Occupational Safety Specialist 1 and 2 in DCBS, and Adult Protective Service Specialist in Department of Human Services. Section 3. The supervisor shall evaluate the employee’s work habits and ability to perform his/her duties satisfactorily and provide the employee feedback within the trial service period. Trial service may be extended in instances where a trial service employee has been on a cumulative leave without pay for fifteen (15) days or more and then only by the number of days the employee was on such leave, or when the Appointing Authority has established a professional or technical training program for positions requiring graduation from a four (4) year college or university or the satisfactory equivalent thereof in training and experience, including but not limited to the training of accountants and auditors, and which is for the purpose of developing the skills or knowledge necessary for competent job performance in the specialized work of such Authority, the employee may be required to train under such program for a period not exceeding six (6) months and the trial service period for such employee shall be the length of the approved training program plus six (6) full months. An employee’s trial service may also be extended for the purpose of developing the skills and/or knowledge necessary for competent job performance. Written notice of the extension will be provided to the employee and a copy of the extension shall be forwarded to SEIU Headquarters and the Labor Relations Unit. Section 4. When, in the judgment of the Appointing Authority, performance has been adequate to clearly demonstrate the competence and fitness of the trial service employee, the Appointing Authority may at any time appoint the employee to regular status. Section 5. Trial service employees may be removed from service when, in the judgment of the Appointing Authority, the employee is unable or unwilling to perform his/her duties satisfactorily or his/her habits and dependability do not merit continuance in the service. Section 6. An employee who is removed from trial service following a lateral transfer or a promotion shall have the right of return to the Agency and the classification or comparable salary level, which the employee previously held, unless charges are filed and he/she is discharged as provided in Article 20--

  • Trial Service Period An employee who has satisfactorily completed their probationary period and who is subsequently appointed to a position in another classification shall serve a twelve (12) month trial service period, in accordance with Section 10.1.3. 10.4.1 The trial service period shall provide the department with the opportunity to observe the employee's work and to train and aid the employee in adjustment to the position, and to revert such an employee whose work performance fails to meet required standards. 10.4.2 An employee who has been appointed from one classification to another classification within the same or different department and who fails to satisfactorily complete the trial service period shall be reverted to a vacant position within that department and classification from which the employee was appointed. 10.4.3 Where no such vacancy exists, such employee shall be given fifteen (15) calendar days' written notice prior to being placed on a Reversion Recall List for their former department and former classification and being removed from the payroll. 10.4.4 An employee’s trial service period may be extended up to three (3) additional months by written mutual agreement between the department, the employee and the Union, subject to approval by the Seattle Human Resources Director prior to expiration of the trial service period. 10.4.5 Employees who have been reverted during the trial service period shall not have the right to appeal the reversion. 10.4.6 The names of regular employees who have been reverted for purposes of re- employment in their former department shall be placed upon a Reversion Recall List for the same classification from which they were promoted or transferred for a period of one (1) year from the date of reversion. 10.4.7 If a vacancy is to be filled in a department and a valid Reversion Recall List for the classification for that vacancy contains the name(s) of eligible employees who have been removed from the payroll from that classification and from that department, such employees shall be reinstated in order of their length of service in that classification. The employee who has the most service in that classification shall be the first reinstated. 10.4.8 An employee whose name is on a Valid Reversion Recall List for a specific job classification who accepts employment with the City in that same job classification shall have their name removed from the Reversion Recall List. Refusal to accept placement from a Reversion Recall List to a position the same, or essentially the same, as that which the employee previously held shall cause an employee’s name to be removed from the Reversion Recall List, which shall terminate rights to reemployment under this Reversion Recall List provision. 10.4.9 An employee whose name is on a valid Reversion Recall List who accepts employment with the City in another class and/or department shall have their name removed from the Reversion Recall List. 10.4.10 A reverted employee shall be paid at the step of the range which the employee normally would have received had the employee not been appointed.

  • Compassionate Care Leave 1. For the purposes of this article “family member” means:

  • Processing of a Grievance It is recognized and accepted by the Union and the Employer that the processing of grievances as hereinafter provided is limited by the job duties and responsibilities of the employees and shall therefore be accomplished during normal working hours only when consistent with such employee duties and responsibilities. The aggrieved employee and a Union representative shall be allowed a reasonable amount of time without loss of pay when a grievance is investigated and presented to the Employer during normal working hours provided that the employee and the Union representative have notified and received the approval of the designated supervisor who has determined that such absence is reasonable and would not be detrimental to the work programs of the Employer.

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