Division of Financial Responsibility. KEY M= Opt-Out to Medicare benefit for Hosptee Service Description Medical Group Hospital Incentive Program PacifiCare Diagnostic Tests - OP - Fac & Prof *** *** *** DME – IP *** *** *** DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics – OP *** *** *** Emergency Room - OP – Fac *** *** *** Emergency Room - OP – E.R. Phys. *** *** *** Endoscopic Studies - IP – Prof *** *** *** Endoscopic Studies - OP – Fac *** *** *** Endoscopic Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization - IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis - OP – Fac (including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP – Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – Prof *** *** *** Hospice Services (Medicare) – IP – Fac & Prof – SH *** *** *** Hospice Services - Prof – CO *** *** *** Hospitalization Services - IP – Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof – CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M= Opt-Out to Medicare benefit for Hosptee Service Description Medical Group~~ CALIFORNIA Secure Horizons Risk Services Agreement (IPA Capitated, Hospital ~~Incentive Program~~ Capitated) List of Benefits IPA Hospital PacifiCare ~~Diagnostic Tests - OP - Fac & Prof~~ 100% Medication *** *** *** DME – IP *** *** *** DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics – OP *** *** *** Emergency Room - OP – Fac *** *** *** Emergency Room - OP – E.R. Phys. *** *** *** Endoscopic Studies - IP – Prof *** *** *** Endoscopic Studies - OP – Fac *** *** *** Endoscopic Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx • Intravenous (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization - IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis - OP – Fac (including all drugsas outpatient or home health) *** *** *** ~~Home Health Care / Homebound Infusion Therapy - OP – Prof~~ • Inpatient *** *** *** ~~Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – Prof~~ • O. P. covered injectables *** *** *** Hospice Services (Medicare) – IP – Fac & Prof – SH *** *** *** Hospice Services - Prof – CO *** *** *** Hospitalization Services - IP – Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP • O. P. non-injectables *** *** *** Mental Health ~~(Crisis Intervention) - OP - Prof – CO~~ *** *** *** ~~MENTAL HEALTH: AB88 Benefits~~ • Inpatient Facility Component *** *** *** • Inpatient Professional Component *** *** *** • Outpatient Professional Component *** *** *** Nuclear Medicine Diagnostics *** *** *** Nuclear Medicine Treatment / Therapy *** *** *** • Facility Component (~~Mental Health Parity applies to CO only~~inpatient) *** *** *** ~~Mental Health – IP & OP - Fac – CO~~ • Facility Component (outpatient) *** *** *** ~~Mental Health – IP & OP - Prof – CO~~ • Professional Component *** *** *** ~~MENTAL HEALTH~~Nutritional/Dietetic Counseling *** *** *** X. X. Xxxxxxxxxxxxx (Xx Xxxx) *** *** *** • Outpatient Diagnostic Services *** *** *** • Inpatient Facility Component *** *** *** • Inpatient Professional Component *** *** *** PMG Referred *** *** *** • Emergent Diagnostics (OB Unit) *** *** *** • ER Treatment *** *** *** Office Visit Supplies, Splints, Bandages, custom fitted appliances, etc. *** *** *** Organ Transplants (non-experimental) *** *** *** • Facility component *** *** *** • Professional component *** *** *** O. P. Surgery *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** (Interpretative MD’s) *** *** *** • Professional Component - other *** *** *** (i.e., Surgeon, Assistant Surgeon, etc.) *** *** *** • Anesthesiology *** *** *** Outpatient Surgery/Facility Based Physicians *** *** *** • Anesthesiology *** *** *** • Audiology *** *** *** • Cardiology *** *** *** • Emergency Room *** *** *** • Diagnostic Services *** *** *** • Neonatology *** *** *** • Neurology *** *** *** • Nephrology *** *** *** • Pathology *** *** *** • Physical Medicine *** *** *** • Pulmonary *** *** *** • Radiology *** *** *** • Radiation Oncology *** *** *** • Surgeon *** *** *** *** All references to the division of financial responsibility have been deleted. Responsible Party List of Benefits IPA Hospital PacifiCare 100% Outpatient Diagnostic Services - Facility and Professional *** *** *** (including but not limited to those listed below) *** *** *** • Angiograms *** *** *** • Cat Scan *** *** *** • 2 D Echo *** *** *** • EEG *** *** *** • EKG *** *** *** • EMG *** *** *** • ENG *** *** *** • MRI *** *** *** • Treadmills *** *** *** • Ultrasound *** *** *** Pediatric Services (newborn) *** *** *** Physical Therapy *** *** *** • Inpatient *** *** *** • Outpatient *** *** *** Physician visits *** *** *** • To Hospital *** *** *** • To S.N.F. *** *** *** • To Patients Home *** *** *** Physician Office Visits/ Consultations *** *** *** Podiatry Services (requires P.M.G. referral) *** *** *** Pregnancy *** *** *** • Professional Component *** *** *** • Facility Component *** *** *** Prosthetic Devices *** *** *** • Surgically Implanted *** *** *** • Outpatient *** *** *** Radiation Therapy *** *** *** • Professional Component *** *** *** • Facility Component (inpatient) *** *** *** • Facility Component (outpatient) *** *** *** Radiology Services *** *** *** • Outpatient *** *** *** • Inpatient *** *** *** • O.P. Surgery *** *** *** Reconstructive Surgery *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** • Prosthetics *** *** *** Refractions *** *** *** *** All references to the division of financial responsibility have been deleted. Responsible Party List of Benefits IPA Hospital PacifiCare 100% Rehabilitation (Short Term, i.e.: ~~Secure Horizons~~ P.T., O.T., Speech, Cardiac Therapy) *** *** *** • Inpatient Facility Component *** *** *** • Inpatient Professional Component *** *** *** • Outpatient Facility Component *** *** *** • Outpatient Professional Component *** *** *** Skilled Nursing Facility *** *** *** Social Services - Medical *** *** *** Specialist Consultations *** *** *** Surgical Supplies *** *** *** • Inpatient *** *** *** • Outpatient Facility *** *** *** • Outpatient IPA *** *** *** TMJ *** *** *** • Dental Treatment *** *** *** • Diagnosis and ~~Commercial~~ Medically Necessary Correction *** *** *** • Inpatient Facility Component *** *** *** Transfusions *** *** *** • From Blood Bank *** *** *** • Autologous Blood Donation *** *** *** Tissue Plasminogen Activator (~~non AB88 Benefits~~TPA) *** *** *** Vision Screening *** *** *** Vision Care *** *** *** • Implanted lenses (cataract surgery) *** *** *** • Lenses and Frames incident to cataract surgery *** *** *** • Non-cataract related lenses and frames *** *** *** • Medically necessary care *** *** *** • Refractions *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. KEY M= M = Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare Diagnostic ~~Tests~~ Test - OP - Fac & Prof *** *** *** DME – - IP *** *** *** DME, . Ostomy Colostomy Supplies. , Prosthetics. /Orthotics – - OP *** *** *** Emergency Room - OP – - Fac *** *** *** Emergency Room - OP – - E.R. Phys. *** *** *** Endoscopic Studies - IP ~~– Prof~~ - *** *** *** Endoscopic Studies - OP – - Fac *** *** *** Endoscopic Studies - OP – - Prof *** *** *** Family Planning - Abortions - OP – - Fac *** *** *** Family Planning - Abortions - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – - OP *** *** *** Family Planning - ~~GIFT~~ GIFT/ZIFT-/IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – - Fac *** *** *** Family Planning - ~~Infertility~~ infertility Procedures - OP – - Prof *** *** *** Family Planning - Infertility Testing - OP – - Prof *** *** *** Family Planning - Sterilization - IP & OP – - Prof *** *** *** Family Planning - Sterilization - IP – - Fac *** *** *** Family Planning - Sterilization - OP – - Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – - OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – - OP *** *** *** Hearing Screening (Audiologic Evaluation) – - OP *** *** *** Hemodialysis / Dialysis - IP & OP – - Prof *** *** *** Hemodialysis / Dialysis - OP – - Fac (including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP – - Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – - Prof *** *** *** Hospice Services (Medicare) – - IP – - Fac & Prof – - SH *** *** *** Hospice Services - Prof – - CO *** *** *** Hospitalization Services - IP – - Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – - OP *** *** *** Infusion therapy – - OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – - OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Prof *** *** *** Laboratory/Pathology - IP – - Fac *** *** *** Lithotripsy - OP – - Fac *** *** *** ~~Lithotripsy~~ Lithorripsy - OP – - Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – - OP *** *** *** Medication - Prescription – - OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof – - CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – - IP & OP - Fac – - CO *** *** *** Mental Health – - IP & OP - Prof – - CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Quality Incentive Program (Prospect Medical Holdings Inc)

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M = Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital ~~Incentive Program~~ PacifiCare ~~Diagnostic Tests~~ Allergy - Serum – OP *** *** *** Allergy - Testing & Tx - OP - Prof. *** *** *** Ambulance (Air and Ground) – OP. in Area *** *** *** Ambulance (Air and Ground) – Out of Area *** *** *** Amniocentesis – OP - Fac & Prof. *** *** *** Anesthesiology – IP & OP – Prof. *** *** *** Autologous Blood Services - OP - Fac & ~~Prof~~ Prof. *** *** *** Brofeedback (Medically Necessary) – OP *** *** *** Blood and Blood Products (Incl. Prof.) *** *** *** Chemical Dependency (Detox) - IP & OP – Fac *** *** *** Chemical Dependency (Detox) - IP & OP – Prof. *** *** *** Chemical Dependency (Rehab) - IP – Fac – CO *** *** *** Chemical Dependency (Rehab) - IP – Fac – SH *** *** *** Chemical Dependency (Rehab) - IP – Prof. – CO *** *** *** Chemical Dependency (Rehab) - IP – Prof. – SH *** *** *** Chemical Dependency (Rehab) - OP – Fac – CO *** *** *** Chemical Dependency (Rehab) - OP – Fac – SH *** *** *** Chemical Dependency (Rehab) - OP – Prof. – CO *** *** *** Chemical Dependency (Rehab) - OP – Prof. – SH *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac *** *** *** Chemotherapy - IP & OP - Prof. *** *** *** Chiropractic – Medical - OP - Fac & Prof. *** *** *** Chiropractic – Supplemental - OP - Fac & Prof. *** *** *** Circumcision - OP - Fac & Prof. *** *** *** Diabetic Management Supplies (to include insulin pumps, Glucometer and test strips) *** *** *** Diagnostic Tests (to include contrast medium) - OP - Fac & Prof. *** *** *** Dialysis (to include Hemodialysis and Peritoneal Dialysis) - IP & OP – Prof. *** *** *** Dialysis (to include Hemodialysis and Peritoneal Dialysis) - Op – Fac (including all drugs) *** *** *** DME (including apnea monitors), Prosthetics (including surgically implanted) Ortho?cs, artificial limbs – IP *** *** *** ~~DME~~DME (including apnea monitors), ~~Ostomy Colostomy Supplies. Prosthetics. Orthotics~~ Prosthetics (including surgically implanted) Ortho?cs, artificial limbs – OP *** *** *** Emergency Room - OP – Fac *** *** *** Emergency Room - OP QP – ~~E.R. Phys~~ER Phys *** *** *** *** All references to the division of financial responsibility have been deleted. Service Description Medical Group Hospital PacifiCare Endoscopic Diagnostic Studies (Performed without Biopsies) *** *** *** Endoscopic Diagnostic Studies ~~- IP – Prof~~ (with Biopsies) *** *** *** ~~Endoscopic Studies~~ Family Planning - Abortions (Elective) - IP and OP ~~– Fac *** *** *** Endoscopic Studies~~ - ~~OP –~~ Prof *** *** *** Family Planning - Abortions (Elective) - IP and OP ~~– Fac *** *** *** Family Planning~~ - ~~Abortions - OP – Prof~~ Fac. *** *** *** Family Planning - Contraceptive Devices - – Insertion and Removal - OP ~~– Prof~~ - Prof. *** *** *** Family Planning - ~~Contraceptive Devices - Non-Rx~~ All “Legend” Contraceptives (~~eg.~~ e.g. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices – Prescription - ~~Prescription –~~ OP *** *** *** Family Planning - ~~GIFT~~ GIFT,ZIFT-/IVF - OP - Fac & Prof. *** *** *** Family Planning - Infertility Procedures/Testing - OP - Prof *** *** *** Family Planning - Infertility ~~Procedures~~ Procedures/Testing - OP ~~– Fac *** *** *** Family Planning~~ - ~~Infertility Procedures - OP – Prof~~ Fac. *** *** *** Family Planning - Infertility Testing - OP ~~– Prof~~ - Prof. *** *** *** Family Planning - Sterilization - IP & OP – - Prof *** *** *** Family Planning - Sterilization - IP – - Fac *** *** *** Family Planning - Sterilization - OP – - Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Fetal Monitoring - IP - Fac & Prof *** *** *** Health Education – - OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – - OP *** *** *** Hearing Screening (~~Audiologic~~ Audiological Evaluation) ~~– OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis~~ - OP ~~– Fac (including all drugs)~~ *** *** *** Home Health Care / Homebound Infusion Therapy - OP ~~– Prof~~ - Prof. *** *** *** Hosp Based Phys Interpretative ~~Serv Incl~~ Sys (to include Radiology & Pathology - IP & OP – - Prof *** *** *** Hospice Services (Medicare) – - IP – - Fac & ~~Prof –~~ Prof. - SH *** *** *** Hospice Services - ~~Prof~~ Fac. - CO *** *** *** Hospice Services – Prof. – CO *** *** *** Hospitalization Services (to include Medical and Surgical) - IP – - Fac *** *** *** Immunizations & Inoculations (~~Medically Necessary~~Preventative) – - OP *** *** *** Infusion ~~therapy –~~ Therapy - OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – AND Not Part of PacifiCare’s Self- Injectable Carve-Out Program (SICOP) - OP *** *** *** ~~Laboratory/~~Laboratory Pathology (Diagnostic Only) - OP – - Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof and Prof. *** *** *** Laboratory/Pathology - IP – - Fac *** *** *** Lithotripsy - OP – - Fac *** *** *** Lithotripsy - OP – - Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – - OP *** *** *** Mental Health (Crisis Intervention) - OP - ~~Prof –~~ Prof. - CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health ~~Parity~~ Panty applies to CO only) *** *** *** Mental Health – - IP & OP - Fac – - CO *** *** *** Mental Health – - IP & OP - ~~Prof –~~ Prof. - CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** Mental Health - IP and OP - Fac - CO *** *** *** Mental Health - IP and OP - Fac. - SH *** *** *** Mental Health - IP and OP - Prof. - CO *** *** *** Mental Health - IP and OP - Prof. - SH *** *** *** Observation Room - OP - Fac *** *** *** Oral Medications (NOT Part of the Outpatient Pharmacy Benefit) -OP *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only OP - Prof. *** *** *** Ostomy/Colostomy Supplies - IP & OP *** *** *** Out of Area (Urgent and Emergent Non-Referred Covered Services) - IP & OP - Fac *** *** *** Out of Area (Urgent and Emergent Non-Referred Covered Services) - IP & OP - Prof. *** *** *** Physician Services (All Professional Services) - IP & OP - Prof *** *** *** Radiation Therapy and Related Professional Services - IP & OP - Prof *** *** *** Radiation Therapy Treatment - IP - Fac (Includes Free Standing) *** *** *** Radiation Therapy Treatment - OP - Fac (Includes Free Standing) *** *** *** Radiology (Diagnostic Theraputic & Nuclear Medicine) - OP *** *** *** Radiology (Diagnostic Theraputic & Nuclear Medicine) - IP *** *** *** *** All references to the division of financial responsibility have been deleted.. Service Description Medical Group Hospital PacifiCare Radiology (Diagnostic Theraputic & Nuclear Medicine: - Outpatient Surgery *** *** *** Radiology - IP - Fac *** *** *** Reconstructive Surgery - IP & OP - Prof. *** *** *** Reconstructive Surgery - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Fac & Prof., IP Prof *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST – IP - Fac. *** *** *** Skilled Nursing Facility - IP - Fac *** *** *** Sleep Studies – OP *** *** *** Surgical Procedures - OP - Fac *** *** *** Surgical Procedures - IP and OP - Prof. *** *** *** Surgical Implants and Devices IP and OP (Permanent, Mechanical and Surgically Implanted AND Includes Corneal Transplants/OLs) *** *** *** TMJ - Evaluation (excludes dental exams/treatment) - OP - Prof *** *** *** Transfusions (including Blood and Blood Products) - OP - Fac & Prof *** *** *** Transplant (excludes corneal): OP and IP Professional Services *** *** *** Transplant (excludes corneal): OP and IP Facility *** *** *** Urgent Care - OP - Fac & Prof *** *** *** Vision - Medical Treatment (to include cataract treatment related items) - OP - Prof. *** *** *** Vision - Refraction for Contact Lenses/Frames - Op - Prof. *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - CO *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - SH *** *** *** *** All references to the division of financial responsibility have been deleted. PACIFICARE OF CALIFORNIA MEDICAL GROUP IPA SERVICES AGREEMENT (SPLIT CAPITATION) EXHIBIT 6 QUALITY INCENTIVE PROGRAM (This Exhibit 6 is an integral part of this Agreement) QUALITY INCENTIVE PROGRAM FOR SECURE HORIZONS MEMBERS

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M = Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital ~~Incentive Program~~ PacifiCare ~~Diagnostic Tests~~ Radiology (Diagnostic/Theraputic & Nuclear Medicines) - ~~OP - Fac & Prof~~ Outpatient Surgery *** *** *** ~~DME~~ Radiology - IP – IP Fac *** *** *** ~~DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics~~ Reconstructive Surgery - IP & OP – OP Prof. *** *** *** ~~Emergency Room~~ Reconstructive Surgery - OP – Fac *** *** *** ~~Emergency Room~~ Rehabilitation - Cardiac/OT/PT/RT/ST - OP – ~~E.R. Phys~~Fac & Prof., IP Prof. *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST – IP – Fac. *** *** *** ~~Endoscopic Studies~~ Skilled Nursing Facility - IP ~~– Prof *** *** *** Endoscopic Studies - OP~~ – Fac *** *** *** ~~Endoscopic~~ Sleep Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** ~~Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility~~ Surgical Procedures - OP – Fac *** *** *** ~~Family Planning - Infertility~~ Surgical Procedures - – IP and OP – Prof *** *** *** ~~Family Planning - Infertility Testing -~~ Surgical Implants and Devices IP and OP – Prof *** *** *** Family Planning - Sterilization - IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval(Permanent, Mechanical and Surgically Implanted AND Includes Corneal Transplants/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis - OP – Fac (including all drugsIOLs) *** *** *** ~~Home Health Care / Homebound Infusion Therapy~~ TMJ - Evaluation (excludes dental exams/treatment) - OP ~~– Prof~~ - Prof. *** *** *** ~~Hosp Based Phys Interpretative Serv Incl Radiology & Pathology~~ Transfusions (including Blood and Blood Products) - ~~IP &~~ OP – ~~Prof~~ Fac & Prof. *** *** *** ~~Hospice~~ Transplant (excludes corneal); OP and IP Professional Services ~~(Medicare) – IP – Fac & Prof – SH~~ *** *** *** ~~Hospice Services~~ Transplant (excludes corneal); OP and IP Facility *** *** *** Urgent Care - ~~Prof~~ OP - Fac & Prof. *** *** *** Vision - Medical Treatment (to include cataract treatment related items)- OP – Prof. *** *** *** Vision - Refraction for Contact Lenses/Frames - OP - Prof. *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP – CO *** *** *** ~~Hospitalization Services~~ Vision Care Materials - ~~IP – Fac *** *** *** Immunizations & Inoculations~~ Contact Lenses/Frames (~~Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology (Diagnostic Only~~non-cataract) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof – CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) SH *** *** *** *** All references to the division of financial responsibility have been deleted.. PACIFICARE OF CALIFORNIA MEDICAL GROUP/IPA SERVICES AGREEMENT (SPLIT CAPITATION) EXHIBIT 6 QUALITY INCENTIVE PROGRAM (This Exhibit 6 is an integral part of this Agreement)

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. KEY M= M = Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare ~~Diagnostic Tests~~ Allergy- Serum-OP *** *** *** Allergy - Testing & Tx - OP - Prof *** *** *** Ambulance (Air and Ground) - OP *** *** *** Amniocentesis - OP - Fac & Prof *** *** *** DME – IP *** *** *** DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics – OP *** *** *** Emergency Room - OP – Fac *** *** *** Emergency Room - OP – E.R. Phys. *** *** *** Endoscopic Studies Anesthesiology - IP – & OP - Prof *** *** *** Endoscopic Studies - OP – Fac *** *** *** Endoscopic Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** Family Planning - GIFT ZIFT-IVF Autologous Blood Services - OP - Fac & Prof *** *** *** ~~Family Planning - Infertility Procedures~~ Biofeedback (Medically Necessary) - OP – *** *** *** Chemical Dependency (Detox) - IP & OP - Fac *** *** *** ~~Family Planning~~ Chemical Dependency (Detox) - ~~Infertility Procedures~~ IP & OP - ~~OP –~~ Prof *** *** *** ~~Family Planning~~ Chemical Dependency (Rehab) - ~~Infertility Testing~~ IP - ~~OP – Prof~~ Fac - CO *** *** *** ~~Family Planning - Sterilization~~ Chemical Dependency (Rehab) - IP ~~& OP – Prof~~ - Fac - SH *** *** *** ~~Family Planning - Sterilization~~ Chemical Dependency (Rehab) - IP ~~– Fac~~ - Prof- CO *** *** *** ~~Family Planning~~ Chemical Dependency (Rehab) - ~~Sterilization~~ IP - ~~OP – Fac~~ Prof - SH *** *** *** ~~Fetal Monitoring~~ Chemical Dependency (Rehab) - OP - Fac - CO *** *** *** Chemical Dependency (Rehab)- OP - Fac - SH *** *** *** Chemical Dependency (Rehab) - OP - Prof- CO *** *** *** Chemical Dependency (Rehab) - OP - Prof - SH *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac & Prof *** *** *** ~~Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – OP *** *** *** Hemodialysis / Dialysis~~ Chemotherapy - IP ~~& OP –~~ - Prof *** *** *** ~~Hemodialysis Dialysis~~ Chiropractic - ~~OP –~~ Medical - OP- Fac ~~(including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP –~~ & Prof *** *** *** ~~Hosp Based Phys Interpretative Serv Incl Radiology~~ Chiropractic - Supplemental - OP - Fac & ~~Pathology - IP & OP –~~ Prof *** *** *** ~~Hospice Services (Medicare) – IP –~~ Circumcision - OP - Fac & Prof – SH *** *** *** Hospice Services - Prof – CO *** *** *** Hospitalization Services - IP – Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof – CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Quality Incentive Program (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M= Opt-Out to Medicare benefit for Hosptee Service Description Medical Group~~ CALIFORNIA Xxxxxx Xxxxxx Risk Services Agreement (IPA Capitated, Hospital ~~Incentive Program~~ Capitated) Responsible Party List of Benefits IPA Hospital PacifiCare ~~Diagnostic Tests - OP - Fac & Prof~~ 100% Home Health Care *** *** *** DME – IP *** *** *** DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics – OP *** *** *** Emergency Room - OP – Fac *** *** *** Emergency Room - OP – E.R. Phys. *** *** *** Endoscopic Studies - IP – Prof *** *** *** Endoscopic Studies - OP – Fac *** *** *** Endoscopic Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (~~eg. Norplant/IUD~~includes IV) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization - IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis - OP – Fac (including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP – Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – Prof *** *** *** Hospice Services ~~(Medicare) – IP – Fac & Prof – SH~~ *** *** *** ~~Hospice Services - Prof – CO~~ • Inpatient *** *** *** ~~Hospitalization Services - IP – Fac~~ • Professional Component *** *** *** ~~Immunizations & Inoculations~~ Hospital Based Physicians (~~Medically Necessary~~Inpatient) ~~– OP~~ *** *** *** ~~Infusion therapy – OP~~ • Anesthesiology *** *** *** ~~Injectables - Not Part of Outpatient Pharmacy Benefits – OP~~ • Audiology *** *** *** ~~Laboratory/Pathology (Diagnostic Only) - OP – Fac~~ • Cardiology *** *** *** ~~Laboratory/Pathology (~~• Diagnostic ~~Only) - OP – Prof~~ Services *** *** *** ~~Laboratory~~• Neonatology *** *** *** • Neurology *** *** *** • Nephrology *** *** *** • Pathology *** *** *** • Physical Medicine *** *** *** • Pulmonary *** *** *** • Radiology *** *** *** • Radiation Oncology *** *** *** • Surgeon *** *** *** Hospitalization, Inpatient Services *** *** *** Supplies and Testing *** *** *** • In Area *** *** *** • Out of Area *** *** *** Immunization and Inoculations *** *** *** • As Medically indicated *** *** *** • For work/~~Pathology - IP – Fac~~ travel *** *** *** Infertility (diagnosis and treatment) *** *** *** • Professional Component *** *** *** • Facility Component *** *** *** Injections and Injected Substances (outpatient) *** *** *** Insulin & Syringes *** *** *** Laboratory Services *** *** *** • Outpatient *** *** *** • Inpatient *** *** *** Lithotripsy ~~- OP – Fac~~ *** *** *** ~~Lithotripsy - OP – Prof~~ • Professional Component *** *** *** ~~Med/Surg Supplies (casts, splints, bandages) - Office – OP~~ • Facility Component *** *** *** ~~Medication - Prescription – OP~~ Mammography *** *** *** Mental Health (Crisis Intervention) - OP - Prof – CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) Marriage Counselling *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M= Opt-Out to Medicare benefit for Hosptee Service Description Medical Group~~ CALIFORNIA Secure Horizons Risk Services Agreement (IPA Capitated, Hospital ~~Incentive Program~~ Capitated) List of Benefits IPA Hospital PacifiCare ~~Diagnostic Tests - OP - Fac & Prof~~ 100% AIDS • Professional Component *** *** *** ~~DME – IP~~ • Facility Component *** *** *** Allergy *** *** *** • Testing *** *** *** • Serum (is not covered by all plans; those with coverage are noted in back of in back of eligibility list) *** *** *** Ambulance, Air or Ground • In Area *** *** *** • Out of Area *** *** *** Amniocentesis *** *** *** Anesthetics, Administration of (Anesthesiology) *** *** *** Apnea Monitor (DME~~, Ostomy~~ ) *** *** *** Artificial Insemination *** *** *** Artificial Limbs (DME) *** *** *** Biofeedback *** *** *** Blood & Blood Products (Including Professional Component) *** *** *** • From Blood Bank *** *** *** • Autologous Blood Donation *** *** *** Chemical Dependency Rehabilitation *** *** *** Chemotherapy *** *** *** • Drugs *** *** *** • Professional Component *** *** *** Chiropractic (requires P.M.G. referral) *** *** *** Circumcision *** *** *** Colostomy ~~Supplies~~Supplies *** *** *** • Outpatient *** *** *** • Inpatient *** *** *** Contact Lenses *** *** *** • Intraocular lens (surgically implanted) *** *** *** • Incident to Cataract Surgery *** *** *** Cosmetic Surgery (Medically Necessary) *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** Dental Services (for repair of accident/injury only) *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** Detox *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** *** All references to the division of financial responsibility have been deleted. ~~Prosthetics. Orthotics – OP~~ Responsible Party List of Benefits IPA Hospital PacifiCare 100% Durable Medical Equipment (DME) *** *** *** • Surgically Implanted *** *** *** • Inpatient *** *** *** • Outpatient *** *** *** • Hearing Aids *** *** *** • Custom made *** *** *** • Custom fitted *** *** *** Emergency Room ~~- OP – Fac~~ Facility Component *** *** *** • In Area *** *** *** • Out of Area *** *** *** Emergency Room Physicians - ~~OP – E.R. Phys.~~ In Area *** *** *** • Initial Treatment *** *** *** • Consults *** *** *** • Out of Area *** *** *** Employment Physical *** *** *** Endoscopic Studies ~~- IP – Prof~~ *** *** *** ~~Endoscopic Studies - OP – Fac~~ • With Biopsy *** *** *** ~~Endoscopic Studies - OP – Prof~~ • Without Biopsy *** *** *** Experimental Procedures *** *** *** Family Planning ~~- Abortions - OP – Fac~~ (e.g.: Abortions, Amniocentesis, Artificial Insemination, Contraceptive Devices, Genetic Testing, Infertility Treatment, Tubal Ligation, Vasectomy) *** *** *** ~~Family Planning - Abortions - OP – Prof~~ • Professional Component *** *** *** ~~Family Planning - Contraceptive Devices - Insertion - OP – Prof~~ • Facility Component *** *** *** ~~Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP~~ • Diaphragms *** *** *** ~~Family Planning - Contraceptive Devices - Prescription – OP~~ • Oral Contraceptives *** *** *** ~~Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof~~ • Invitro Fertilization *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - • Reversal of Sterilization ~~- IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac~~ *** *** *** Fetal Monitoring ~~- OP - Fac & Prof~~ *** *** *** • Outpatient (diagnostic) *** *** *** • Inpatient *** *** *** Genetic Testing *** *** *** Health Education ~~– OP~~ *** *** *** Health ~~Eval/Physical~~ Evaluation (Physical) *** *** *** Hearing ~~Aids/Molds – OP~~ Aids *** *** *** Hearing Screening ~~(Audiologic Evaluation) – OP~~ *** *** *** Hemodialysis ~~/ Dialysis - IP & OP – Prof~~ *** *** *** ~~Hemodialysis Dialysis - OP – Fac (including all drugs)~~ • Inpatient *** *** *** Home Health Care / Homebound Infusion Therapy - OP – Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – Prof *** *** *** Hospice Services (Medicare) – IP – Fac & Prof – SH *** *** *** Hospice Services - Prof – CO *** *** *** Hospitalization Services - IP – Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of • Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof – CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M - Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare Allergy - Serum - OP *** *** *** Allergy - Testing & Tx - OP – Prof *** *** *** Ambulance (Air and Ground) – OP *** *** *** Amniocentesis - OP - Fac & Prof *** *** *** Anesthesiology - IP & OP – Prof *** *** *** Autologous Blood Services - OP - Fac & Prof *** *** *** Biofeedback (Medically Necessary) – OP *** *** *** Chemical Dependency (Detox) - IP & OP – Fac *** *** *** Chemical Dependency (Detox) - IP & OP – Prof *** *** *** Chemical Dependency (Rehab) - IP - Fac – CO *** *** *** Chemical Dependency (Rehab) - IP - Prof– CO *** *** *** Chemical Dependency (Rehab) - OP - Fac – CO *** *** *** Chemical Dependency (Rehab) - OP - Prof– CO *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral and including Lupron and Viadur J Codes when used in conjunction with Chemotherapy, as follows: J9217, J9218, J9219) - OP - Fac & Prof *** *** *** Chemotherapy - IP – Prof *** *** *** Chiropractic - Medical - OP - Fac & Prof *** *** *** Chiropractic - Supplemental - OP - Fac & Prof *** *** *** Circumcision - OP - Fac & Prof *** *** *** Diagnostic Tests - OP - Fac & Prof *** *** *** DME – IP *** *** *** DME, ~~Ostomy~~ Ostomy/Colostomy Supplies. Prosthetics. /Orthotics – - OP *** *** *** Emergency Room - OP – Fac *** *** *** Emergency Room - OP – Professional and E.R. Phys. *** *** *** Endoscopic Studies - IP IP– Prof *** *** *** Endoscopic Studies - OP – Fac *** *** *** *** All references to the division of financial responsibility have been deleted. Service Description Medical Group Hospital Incentive Program PacifiCare Endoscopic Studies - OP OP– Prof *** *** *** Family Planning - Abortions - OP – - Fac *** *** *** Family Planning - Abortions - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – - OP *** *** *** Family Planning - ~~GIFT~~ GIFT/ZIFT-/IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – - Fac *** *** *** Family Planning - Infertility Procedures - OP – - Prof *** *** *** Family Planning - Infertility Testing - OP – - Prof *** *** *** Family Planning - Sterilization - IP & OP – - Prof *** *** *** Family Planning - Sterilization - IP – - Fac *** *** *** Family Planning - Sterilization - OP – - Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – - OP *** *** *** Hemodialysis/Dialysis - IP & OP - Prof *** *** *** Hemodialysis / Dialysis ~~- IP &~~ – OP – ~~Prof~~ Fac (including all drugs) *** *** *** ~~Hemodialysis Dialysis~~ Hemophilia Factors - Not Part of Outpatient Pharmacy Benefits – OP ~~– Fac (including all drugs)~~ - CO *** *** *** Home Health Care / Homebound Infusion Therapy - OP – Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – - Prof *** *** *** Hospice Services ~~(Medicare) –~~ - IP ~~– Fac & Prof – SH *** *** *** Hospice Services~~ - ~~Prof~~ Prof– CO *** *** *** Hospitalization Services - IP – –Fac *** *** *** Immunizations & Inoculations (Medically Necessary) ~~– OP *** *** *** Infusion therapy –~~ - OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – - OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – - Fac *** *** *** Lithotripsy - OP – - Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – - OP *** *** *** Medication - Prescription – - OP *** *** *** Mental Health (Crisis Intervention) - OP - ~~Prof –~~ Prof- CO *** *** *** MENTAL HEALTH: ~~AB88 Benefits (Mental Health Parity applies to CO only)~~ *** *** *** Mental Health – IP & and OP - – Fac – CO *** *** *** Mental Health - IP and OP – ~~IP & OP - Prof –~~ Prof- CO *** *** *** ~~MENTAL HEALTH: Secure Horizons and Commercial~~ Observation Room - OP – Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Prof *** *** *** Out of Area - IP & OP – Fac *** *** *** Out of Area - IP & OP – Prof *** *** *** Outpatient Surgery - OP – Fac *** *** *** Outpatient Surgery - OP - Prof *** *** *** Physician Services (~~non AB88 Benefits~~All Professional Services) - IP & OP - Prof *** *** *** Prosthetics - Surgical Implants - OP *** *** *** Radiation Therapy - IP & OP - Prof *** *** *** Radiation Therapy - OP – Fac and/ or freestanding facility *** *** *** Radiology (Diagnostic Only) - OP – Fac *** *** *** *** All references to the division of financial responsibility have been deleted.. Service Description Medical Group Hospital Incentive Program PacifiCare Radiology (Diagnostic Only) - OP – Prof *** *** *** Radiology - IP – Fac *** *** *** Reconstructive Surgery - IP & OP – Prof *** *** *** Reconstructive Surgery - OP – Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP – Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP – Prof *** *** *** Skilled Nursing Facility - IP – Fac *** *** *** Sleep Studies – OP *** *** *** TMJ - Evaluation (excludes dental exams/treatment) - OP - Prof *** *** *** Transfusions - OP - Fac *** *** *** Transplant Candidacy and Maintenance; OP and IP Professional *** *** *** Transplant Candidacy and Maintenance: OP and IP Facility *** *** *** Transplant Evaluation (excludes corneal); OP and IP Professional. See Note (3). *** *** *** Transplant Evaluation (excludes corneal); OP and IP Facility. See Note (3). *** *** *** Transplant Procedure and Procurement (excludes corneal); OP and IP Professional Services. See Note (3). *** *** *** Transplant Procedure and Procurement (excludes corneal); OP and IP Facility. See Note (3). *** *** *** Transplant Related Transportation and Housing - NPTN specific benefit. See Note (3). *** *** *** Transplant Follow-up (excludes corneal) OP and IP Professional; Year 1 - See Note (3). *** *** *** Transplant Follow-up (excludes corneal); OP and IP Facility; Year 1. (See Note (3) *** *** *** Transplant Years 2 - 5 Follow-Up (excludes corneal); OP and IP Professional *** *** *** Transplant Years 2 – 5 Follow-Up (excludes corneal); OP and IP Facility *** *** *** Urgent Care - OP - Fac & Prof *** *** *** Vision - Medical Treatment – OP - Prof *** *** *** Vision - Refraction for Contact Lenses/Frames - OP - Prof *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - CO *** *** *** Notes:

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. KEY M= M - Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare ~~Diagnostic Tests -~~ Mental Health – IP and OP - – Fac ~~& Prof~~ – CO *** *** *** ~~DME~~ Mental Health – IP and OP – Fac – SH *** *** *** ~~DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics~~ Mental Health – IP and OP – Prof – CO *** *** *** ~~Emergency~~ Mental Health – IP and OP – Prof – SH *** *** *** Observation Room - OP – Fac *** *** *** ~~Emergency Room~~ Oral Surgery Dental Services - Accident & Injury Only - OP ~~– E.R. Phys.~~ - Fac *** *** *** ~~Endoscopic Studies~~ Oral Surgery Dental Services - ~~IP –~~ Accident & Injury Only - OP - Prof *** *** *** ~~Endoscopic Studies~~ Out of Area - IP & OP – Fac *** *** *** Endoscopic Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization Out of Area - IP & OP – Prof *** *** *** ~~Family Planning - Sterilization - IP~~ Outpatient Surgery – ~~Fac *** *** *** Family Planning - Sterilization -~~ OP – Fac *** *** *** ~~Fetal Monitoring -~~ Outpatient Surgery – OP ~~- Fac &~~ – Prof *** *** *** ~~Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening~~ Physician Services (~~Audiologic Evaluation~~All Professional Service) ~~– OP *** *** *** Hemodialysis / Dialysis~~ - IP & OP – Prof *** *** *** ~~Hemodialysis Dialysis~~ Prosthetics - Surgical Implants – OP ~~– Fac (including all drugs)~~ *** *** *** ~~Home Health Care / Homebound Infusion~~ Radiation Therapy ~~- OP~~ – ~~Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology -~~ IP & OP – Prof *** *** *** ~~Hospice Services (Medicare)~~ Radiation Therapy – IP OP – Fac ~~& Prof – SH~~ and/ or freestanding facility *** *** *** Hospice Services - Prof – CO *** *** *** Hospitalization Services - IP – Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology Radiology (Diagnostic Only) - OP – Fac *** *** *** ~~Laboratory/Pathology~~ Radiology (Diagnostic Only) - OP – Prof *** *** *** ~~Laboratory/Pathology~~ Radiology - IP – Fac *** *** *** ~~Lithotripsy~~ Reconstructive Surgery - IP & OP – Prof *** *** *** Reconstructive Surgery - OP – Fac *** *** *** ~~Lithotripsy~~ Rehabilitation - Cardiac. OT/PT/RT/ST - OP – Fac *** *** *** Rehabilitation - Cardiac. OT/PT/RT/ST - OP – Prof *** *** *** ~~Med/Surg Supplies (casts, splints, bandages)~~ Skilled Nursing Facility - ~~Office~~ IP – Fac *** *** *** Sleep Studies – OP *** *** *** ~~Medication~~ TMJ - ~~Prescription~~ Evaluation (excludes dental exams/treatment) - OP – OP Prof *** *** *** ~~Mental Health~~ Transfusions - OP – Fac *** *** *** Transplant Candidacy and Maintenance: OP and IP Professional *** *** *** Transplant Candidacy and Maintenance: OP and IP Facility *** *** *** Transplant Evaluation (~~Crisis Intervention~~excludes corneal); OP and IP Professional. See Note (1). *** *** *** Transplant Evaluation (excludes corneal); OP and IP Facility. See Note (1) *** *** *** Transplant Procedure and Procurement (excludes corneal); OP and IP Professional Services. See Note (1). *** *** *** Transplant Procedure and Procurement (excludes corneal); OP and IP Facility. See Note (1). *** *** *** Transplant Related Transportation and Housing - NPTN specific benefit. See Note(1). *** *** *** Transplant Follow-up (excludes corneal); OP and IP Professional; Year 1. See Note (1). *** *** *** Transplant Follow-up (excludes corneal); OP and IP Facility; Year 1. See Note (I) *** *** *** Transplant Years 2 – 5 Follow-up (excludes corneal); OP and IP Professional *** *** *** Transplant Years 2 – 5; Follow-up (excludes corneal); OP and IP Facility *** *** *** Urgent Care - OP - Fac & Prof *** *** *** Vision - Medical Treatment – OP – Prof *** *** *** Vision - Refraction for Contact Lenses/Frames - OP – Prof *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - ~~Prof –~~ CO *** *** *** ~~MENTAL HEALTH: AB88 Benefits~~ Vision Care Materials - Contact Lenses/Frames (~~Mental Health Parity applies to CO only~~non-cataract) *** *** *** Mental Health – IP & - OP - ~~Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits)~~ SH *** *** *** *** All references to the division of financial responsibility have been deleted.. Notes:

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. KEY M= M = Opt-~~Out~~ out to Medicare benefit ~~for Hosptee~~ forHospice Service Description Medical Group Hospital Incentive Program PacifiCare MENTAL HEALTH: Secure Horizons and Commercial (xxx, XX00 Benefits) *** *** *** Mental Health - IP and OP - Fac - CO *** *** *** Mental Health - IP and OP - Fac - SH *** *** *** Mental Health - IP and OP - Prof- CO *** *** *** Mental Health - IP and OP - Prof - SH *** *** *** Observation Room - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Prof *** *** *** Out of Area - IP & OP - Fac *** *** *** Out of Area - IP & OP - Prof *** *** *** Outpatient Surgery - OP - Fac *** *** *** Outpatient Surgery - OP - Prof *** *** *** Physician Services (All Professional Services) - IP & OP - Prof *** *** *** Prostheties - Surgical Implants - OP *** *** *** Radiation Therapy - IP & OP - Prof *** *** *** Radiation Therapy - OP - Fac and / or freestanding facility *** *** *** Radiology (Diagnostic ~~Tests~~ Only) - OP - Fac *** *** *** Radiology (Diagnostic Only) - OP - Prof *** *** *** Radiology - IP - Fac *** *** *** Reconstructive Surgery - IP & OP - Prof *** *** *** Reconstructive Surgery - OP - Fac *** *** *** Rehabilitation - Cardiac. OT/PT/RT/ST - OP - Fac *** *** *** Rehabilitation - Cardiac. OT/PT/RT/ST - OP - Prof *** *** *** Skilled Nursing Facility - IP - Fac *** *** *** Sleep Studies - OP *** *** *** TMJ - Evaluation (excludes dental exams/treatment) - OP - Prof *** *** *** Transfusions - OP - Fac *** *** *** Transplant Candidacy and Maintenance; OP and IP Professional *** *** *** Transplant Candidacy and Maintenance; OP and IP Facility *** *** *** Transplant Evaluation (excludes corneal); OP and IP Professional. See Note (1). *** *** *** Transplant Evaluation (excludes corneal); OP and IP Facility. See Note (1). *** *** *** Transplant Procedure and Procurement (excludes corneal); OP and IP Professional Services. See Note (1). *** *** *** Transplant Procedure and Procurement (excludes corneal); OP and IP Facility. See Note (1). *** *** *** Transplant Related Transportation and Housing - NPTN specific benefit. See Note (1). *** *** *** Transplant Follow-up (excludes corneal); OP and IP Professional; Year I. See Note (1). *** *** *** Transplant Follow-up (excludes corneal); OP and IP Facility; Year 1. See Note (1) *** *** *** Transplant Years 2 - 5 Follow-up (excludes corneal); OP and IP Professional *** *** *** Transplant Years 2 -5; Follow-up (excludes corneal); OP and IP Facility *** *** *** Urgent Care - OP - Fac & Prof *** *** *** ~~DME – IP *** *** *** DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics – OP *** *** *** Emergency Room~~ Vision - Medical Treatment - OP ~~– Fac *** *** *** Emergency Room~~ - ~~OP – E.R. Phys. *** *** *** Endoscopic Studies - IP –~~ Prof *** *** *** ~~Endoscopic Studies~~ Vision - OP – Fac *** *** *** Endoscopic Studies - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. NorplantRefraction for Contact Lenses/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – OP *** *** *** Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization - IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (Audiologic Evaluation) – OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis - OP – Fac (including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP – Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – Prof *** *** *** Hospice Services (Medicare) – IP – Fac & Prof – SH *** *** *** Hospice Services - Prof – CO *** *** *** Hospitalization Services - IP – Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – OP *** *** *** Infusion therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP *** *** *** Mental Health (Crisis Intervention) Frames - OP - Prof – CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP - Prof – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Quality Incentive Program (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ (PacifiCare Secure Horizons and Commercial Plan) The following matrix outlines the division of financial responsibility between PacifiCare, Medical Group and the Hospital Incentive Program, the intent being to clarify Covered Services categories in order to provide for accurate administration. The matrix serves as a model under which broad Covered Service categories suggest the appropriate financial responsibility for Covered Services not specifically listed. The applicable Subscriber Agreement should be consulted for an accurate and complete description of Covered Services and the Provider Manual for administrative clarification. Division of Financial Responsibility KEY: M-Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare Allergy-Serum-OP *** *** *** Allergy-Testing & Tx - OP-Prof *** *** *** Ambulance (Air and Ground) - OP *** *** *** Amniocentesis - OP - Fac & Prof *** *** *** Anesthesiology - IP & OP - Prof *** *** *** Autologus Blood Services - OP - Fac & Prof *** *** *** Biofeedback (Medically Necessary) - OP *** *** *** Chemical Dependency (Detox) - IP & OP - Fac *** *** *** Chemical Dependency (Detox) - IP & OP - Prof *** *** *** Chemical Dependency (Rehab) - IP - Fac - CO *** *** *** Chemical Dependency (Rehab) - IP - Fac - SH *** *** *** Chemical Dependency (Rehab) - IP - Prof - CO *** *** *** Chemical Dependency (Rehab) - IP - Prof - SH *** *** *** Chemical Dependency (Rehab) - OP - Fac - CO *** *** *** Chemical Dependency (Rehab) - OP - Fac - SH *** *** *** Chemical Dependency (Rehab) - OP - Prof - CO *** *** *** Chemical Dependency (Rehab) - OP - Prof - SH *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac & Prof *** *** *** Chemotherapy - IP - Prof *** *** *** Chiropractic - Medical - OP - Fac & Prof *** *** *** Chiropractic - Supplemental - OP - Fac & Prof *** *** *** Circumcision - OP - Fac & Prof *** *** *** Diagnostic Tests - OP - Fac & Prof *** *** *** DME – - IP *** *** *** DME, ~~Ostomy~~ Ostomy/Colostomy Supplies. , Prosthetics~~. Orthotics –~~ /Orthorics - OP *** *** *** Emergency Room - OP – - Fac *** *** *** Emergency Room - OP ~~– E.R. Phys.~~ - Prof *** *** *** Endoscopic Studies - IP – - Prof *** *** *** Endoscopic Studies - OP – - Fac *** *** *** Endoscopic Studies - OP – - Prof *** *** *** Family Planning - Abortions - OP – - Fac *** *** *** Family Planning - Abortions - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP ~~*** *** ***~~ Family Planning - Contraceptive Devices - Prescription – - OP *** *** *** Family Planning - ~~GIFT~~ GIFT/ZIFT-/IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – - Fac *** *** *** Family Planning - Infertility Procedures - OP – - Prof *** *** *** Family Planning - Infertility Testing - OP – - Prof *** *** *** Family Planning - Sterilization - IP & OP – - Prof *** *** *** Family Planning - Sterilization - IP – - Fac *** *** *** Family Planning - Sterilization - OP – - Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – - OP *** *** *** Health Eval/~~Physical~~ physical *** *** *** Hearing Aids/Molds – - OP *** *** *** Hearing Screening (Audiologic Evaluation) – - OP *** *** *** Hemodialysis / Dialysis - IP & OP – - Prof *** *** *** Hemodialysis / Dialysis - OP – - Fac ~~(including all drugs)~~ *** *** *** *** All references to the division of financial responsibility have been deleted. Home Health Care / ~~Homebound~~ Home Infusion Therapy - OP – - Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – - Prof *** *** *** Hospice Services (Medicare) – - IP – - Fac & Prof – - SH *** *** *** Hospice Services - IP - Prof – - CO *** *** *** Hospitalization Services - IP – - Fac *** *** *** Immunizations & Inoculations (Medically Necessary~~) – OP *** *** *** Infusion therapy –~~ ] - OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – - OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Prof *** *** *** Laboratory/Pathology - IP – - Fac *** *** *** Lithotripsy - OP – - Fac *** *** *** Lithotripsy - OP – - Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – - OP *** *** *** Medication - Prescription – - OP *** *** *** Mental Health (Crisis ~~Intervention~~intervention) - OP - Prof ~~– CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP~~ - ~~Fac –~~ CO *** *** *** Mental Health – - IP ~~& OP~~ - ~~Prof –~~ Fac - CO *** *** *** ~~MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits)~~ Mental Health - IP - Fac - SH *** *** *** Mental Health - IP - Prof - CO *** *** *** Mental Health - IP - Prof - SH *** *** *** Mental Health - OP - Fac - CO *** *** *** Mental Health - OP - Fac - SH *** *** *** Mental Health - OP - Prof - CO *** *** *** Mental Health - OP - Prof - SH *** *** *** Observation Room - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Prof *** *** *** Out of Area -IP & OP - Fac *** *** *** Out of Area - IP & OP - Prof *** *** *** Outpatient Surgery - OP - Fac *** *** *** Outpatient Surgery - OP - Prof *** *** *** Physician Services (All ~~references to the division of financial responsibility have been deleted.~~Professional Services) - IP & OP - Prof *** *** *** Prosthetics - Surgical Implants - OP *** *** *** Radiation Therapy - IP & OP - Prof *** *** *** Radiation Therapy - OP - Fac *** *** *** Radiology (Diagnostic Only) - OP - Fac *** *** *** Radiology (Diagnostic Only) - OP - Prof *** *** *** Radiology - IP - Fac *** *** *** Reconstructive Surgery - IP & OP - Prof *** *** *** Reconstructive Surgery - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Prof *** *** *** Skilled Nursing Facility - IP - Fac *** *** *** Sleep Studies - OP *** *** *** TMJ - Evaluation (excludes dental exams/treatment) - OP - Prof *** *** *** Transfusions - OP - Fac *** *** *** Transplants - IP - Fac *** *** *** Transplants - IP - Prof *** *** *** Urgent Care - OP - Fac & Prof *** *** *** Vision - Medical Treatment - OP - Prof *** *** *** Vision - Refraction for Contact Lenses/Frames - OP - Prof *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - CO *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract)- OP - SH *** *** ***

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M= Opt-Out to Medicare benefit for Hosptee Service Description Medical Group~~ CALIFORNIA Commercial Risk Services Agreement (IPA Capitated, Hospital ~~Incentive Program~~ Capitated) List of Benefits IPA Hospital PacifiCare ~~Diagnostic Tests - OP - Fac & Prof~~ 100% AIDS • Professional Component *** *** *** ~~DME – IP~~ • Facility Component *** *** *** Allergy *** *** *** • Testing *** *** *** • Serum (is not covered by all plans; those with coverage are noted in back of eligibility list) *** *** *** Ambulance, Air or Ground • In Area *** *** *** • Out of Area *** *** *** Amniocentesis *** *** *** Anesthetics, Administration of (Anesthesiology) *** *** *** Apnea Monitor (DME~~, Ostomy~~ ) *** *** *** Artificial Insemination *** *** *** Artificial Limbs (DME) *** *** *** Biofeedback *** *** *** Blood & Blood Products (Including Professional Component) *** *** *** • From Blood Bank *** *** *** • Autologous Blood Donation *** *** *** Chemical Dependency Rehabilitation *** *** *** Chemotherapy *** *** *** • Drugs *** *** *** • Professional Component *** *** *** Chiropractic (requires P.M.G. referral) *** *** *** Circumcision *** *** *** Colostomy ~~Supplies~~Supplies *** *** *** • Outpatient *** *** *** • Inpatient *** *** *** Contact Lenses *** *** *** • Intraocular lens (surgically implanted) *** *** *** • Incident to Cataract Surgery *** *** *** Cosmetic Surgery (Medically Necessary) *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** Dental Services (for repair of accident/injury only) *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** Detox *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** *** All references to the division of financial responsibility have been deleted. ~~Prosthetics. Orthotics – OP~~ Responsible Party List of Benefits IPA Hospital PacifiCare 100% Durable Medical Equipment (DME) *** *** *** • Surgically Implanted *** *** *** • Inpatient *** *** *** • Outpatient *** *** *** • Hearing Aids *** *** *** • Custom Made *** *** *** • Custom fitted *** *** *** Emergency Room ~~- OP – Fac~~ Facility Component *** *** *** • In Area *** *** *** • Out of Area *** *** *** Emergency Room ~~- OP~~ Physicians – ~~E.R. Phys.~~ In Area *** *** *** • Initial Treatment *** *** *** • Consults *** *** *** • Out of Area *** *** *** Employment Physical *** *** *** Endoscopic Studies ~~- IP – Prof~~ *** *** *** ~~Endoscopic Studies - OP – Fac~~ • With Biopsy *** *** *** ~~Endoscopic Studies - OP – Prof~~ • Without Biopsy *** *** *** Experimental Procedures *** *** *** Family Planning ~~- Abortions - OP – Fac~~ (e.g.: Abortions, Amniocentesis, Artificial Insemination, Contraceptive Devices, Genetic Testing, Infertility Treatment, Tubal Ligation, Vasectomy) *** *** *** ~~Family Planning - Abortions - OP – Prof~~ • Professional Component *** *** *** ~~Family Planning - Contraceptive Devices - Insertion - OP – Prof~~ • Facility Component *** *** *** ~~Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP~~ • Diaphragms *** *** *** ~~Family Planning - Contraceptive Devices - Prescription – OP~~ • Oral Contraceptives *** *** *** ~~Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof~~ • Invitro Fertilization *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - • Reversal of Sterilization ~~- IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - Sterilization - OP – Fac~~ *** *** *** Fetal Monitoring ~~- OP - Fac & Prof~~ *** *** *** • Outpatient (diagnostic) *** *** *** • Inpatient *** *** *** Genetic Testing *** *** *** Health Education ~~– OP~~ *** *** *** Health ~~Eval/Physical~~ Evaluation (Physical) *** *** *** Hearing ~~Aids/Molds – OP~~ Aids *** *** *** Hearing Screening ~~(Audiologic Evaluation) – OP~~ *** *** *** Hemodialysis ~~/ Dialysis - IP & OP – Prof~~ *** *** *** ~~Hemodialysis Dialysis - OP – Fac (including all drugs)~~ • Inpatient *** *** *** ~~Home Health Care / Homebound Infusion Therapy - OP – Prof~~ • Outpatient *** *** *** ~~Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – Prof~~ *** All references to the division of financial responsibility have been deleted. Responsible Party List of Benefits IPA Hospital PacifiCare 100% Home Health Care *** *** *** (Includes IV) *** *** *** Hospice Services ~~(Medicare) – IP – Fac & Prof – SH~~ *** *** *** ~~Hospice Services - Prof – CO~~ • Inpatient *** *** *** ~~Hospitalization Services - IP – Fac~~ • Professional Component *** *** *** ~~Immunizations & Inoculations~~ Hospital Based Physicians (~~Medically Necessary~~Inpatient) ~~– OP~~ *** *** *** ~~Infusion therapy – OP~~ • Anesthesiology *** *** *** ~~Injectables - Not Part of Outpatient Pharmacy Benefits – OP~~ • Audiology *** *** *** ~~Laboratory/Pathology (Diagnostic Only) - OP – Fac~~ • Cardiology *** *** *** ~~Laboratory/Pathology (~~• Diagnostic ~~Only) - OP – Prof~~ Services *** *** *** ~~Laboratory~~• Neonatology *** *** *** • Neurology *** *** *** • Nephrology *** *** *** • Pathology *** *** *** • Physical Medicine *** *** *** • Pulmonary *** *** *** • Radiology *** *** *** • Radiation Oncology *** *** *** • Surgeon *** *** *** Hospitalization, Inpatient Services *** *** *** Supplies and Testing *** *** *** • In Area *** *** *** • Out of Area *** *** *** Immunization and Inoculations *** *** *** • As Medically indicated *** *** *** • For work/~~Pathology - IP – Fac~~ travel *** *** *** Infertility (diagnosis and treatment) *** *** *** • Professional Component *** *** *** • Facility Component *** *** *** Injections and Injected Substances *** *** *** (outpatient) *** *** *** Insulin & Syringes *** *** *** Laboratory Services *** *** *** • Outpatient *** *** *** • Inpatient *** *** *** Lithotripsy ~~- OP – Fac~~ *** *** *** ~~Lithotripsy - OP – Prof~~ • Professional Component *** *** *** ~~Med/Surg Supplies (casts, splints, bandages) - Office – OP~~ • Facility Component *** *** *** Mammography *** *** *** Marriage Counseling *** *** *** *** All references to the division of financial responsibility have been deleted. Responsible Party List of Benefits IPA Hospital PacifiCare 100% Medication ~~- Prescription – OP~~ *** *** *** • Intravenous (as outpatient or home health) *** *** *** • Inpatient *** *** *** • O.P. covered injectables *** *** *** • O.P. non-injectables *** *** *** Mental Health ~~(Crisis Intervention) - OP - Prof – CO~~ *** *** *** ~~MENTAL HEALTH: AB88 Benefits~~ • Inpatient Facility Component *** *** *** • Inpatient Professional Component *** *** *** • Outpatient Professional Component *** *** *** Nuclear Medicine Diagnostics *** *** *** Nuclear Medicine Treatment/Therapy *** *** *** • Facility Component (~~Mental Health Parity applies to CO only~~inpatient) *** *** *** ~~Mental Health – IP & OP - Fac – CO~~ • Facility Component (outpatient) *** *** *** ~~Mental Health – IP & OP - Prof – CO~~ • Professional Component *** *** *** ~~MENTAL HEALTH~~Nutritional/Dietetic Counseling *** *** *** O.B. Complications (In Area) *** *** *** • Outpatient Diagnostic Services *** *** *** • Inpatient Facility Component *** *** *** • Inpatient Professional Component *** *** *** PMG Referred *** *** *** • Emergent Diagnostics (OB Unit) *** *** *** • ER Treatment *** *** *** Office Visit Supplies, Splints, Bandages, custom fitted appliances, etc. *** *** *** Organ Transplants (non-experimental) *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** O.P. Surgery *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** (Interpretative MD’s) *** *** *** • Professional Component – other *** *** *** (i.e., Surgeon, Assistant Surgeon, etc.) *** *** *** • Anesthesiology *** *** *** Outpatient Surgery/Facility Based Physicians *** *** *** • Anesthesiology *** *** *** • Audiology *** *** *** • Cardiology *** *** *** • Emergency Room *** *** *** • Diagnostic Services *** *** *** • Neonatology *** *** *** • Neurology *** *** *** • Nephrology *** *** *** • Pathology *** *** *** • Physical Medicine *** *** *** • Pulmonary *** *** *** • Radiology *** *** *** • Radiation Oncology *** *** *** • Surgeon *** *** *** *** All references to the division of financial responsibility have been deleted. Responsible Party List of Benefits IPA Hospital PacifiCare 100% Outpatient Diagnostic Services – Facility and Professional *** *** *** (including but not limited to those listed below) *** *** *** • Angiograms *** *** *** • Cat Scan *** *** *** • 2 D Echo *** *** *** • EEG *** *** *** • EKG *** *** *** • EMG *** *** *** • ENG *** *** *** • MRI *** *** *** • Treadmills *** *** *** • Ultrasound *** *** *** Pediatric Services (newborn) *** *** *** Physical Therapy *** *** *** • Inpatient *** *** *** • Outpatient *** *** *** Physician Visits *** *** *** • To Hospital *** *** *** • To S.N.F. *** *** *** • To Patients Home *** *** *** Physician Office Visits/Consultations *** *** *** Podiatry Services (requires P.M.G. referral) *** *** *** Pregnancy *** *** *** • Professional Component *** *** *** • Facility Component *** *** *** Prosthetic Devices *** *** *** • Surgically Implanted *** *** *** • Outpatient *** *** *** Radiation Therapy *** *** *** • Professional Component *** *** *** • Facility Component (inpatient) *** *** *** • Facility Component (outpatient) *** *** *** Radiology Services *** *** *** • Outpatient *** *** *** • Inpatient *** *** *** • O.P. Surgery *** *** *** Reconstructive Surgery *** *** *** • Facility Component *** *** *** • Professional Component *** *** *** • Prosthetics *** *** *** Refractions *** *** *** *** All references to the division of financial responsibility have been deleted. Responsible Party List of Benefits IPA Hospital PacifiCare 100% Rehabilitation (Short Term, i.e.: ~~Secure Horizons~~ P.T., O.T., Speech, Cardiac Therapy) *** *** *** • Inpatient Facility Component *** *** *** • Inpatient Professional Component *** *** *** • Outpatient Facility Component *** *** *** • Outpatient Professional Component *** *** *** Skilled Nursing Facility *** *** *** Social Services – Medical *** *** *** Specialist Consultations *** *** *** Surgical Supplies *** *** *** • Inpatient *** *** *** • Outpatient Facility *** *** *** • Outpatient IPA *** *** *** TMJ *** *** *** • Dental Treatment *** *** *** • Diagnosis and ~~Commercial~~ Medically Necessary Correction *** *** *** • Inpatient Facility Component *** *** *** Transfusions *** *** *** • From Blood Bank *** *** *** • Autologous Blood Donation *** *** *** Tissue Plasminogen Activator (~~non AB88 Benefits~~TPA) *** *** *** Vision Screening *** *** *** Vision Care *** *** *** • Implanted lenses (cataract surgery) *** *** *** • Lenses and Frames incident to cataract surgery *** *** *** • Non-cataract related lenses and frames *** *** *** • Medically necessary care *** *** *** • Refractions *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M = Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital ~~Incentive Program~~ PacifiCare ~~Diagnostic Tests~~ Allergy - Serum – OP *** *** *** Allergy - Testing & Tx - OP – Prof. *** *** *** Ambulance (Air and Ground) – OP. In Area *** *** *** Ambulance (Air and Ground) – Out of Area *** *** *** Amniocentesis – OP - Fac & Prof. *** *** *** Anesthesiology – IP & OP – Prof. *** *** *** Autologous Blood Services - OP - Fac & ~~Prof~~ Prof. *** *** *** Biofeedback (Medically Necessary) – OP *** *** *** Blood and Blood Products (Incl. Prof.) *** *** *** Chemical Dependency (Detox) - IP & OP – Fac *** *** *** Chemical Dependency (Detox) - IP & OP – Prof. *** *** *** Chemical Dependency (Rehab) - IP – Fac – CO *** *** *** Chemical Dependency (Rehab) - IP – Fac – SH *** *** *** Chemical Dependency (Rehab) - IP – Prof. – CO *** *** *** Chemical Dependency (Rehab) - IP – Prof. – SH *** *** *** Chemical Dependency (Rehab) - OP – Fac – CO *** *** *** Chemical Dependency (Rehab) - OP – Fac – SH *** *** *** Chemical Dependency (Rehab) - OP – Prof. – CO *** *** *** Chemical Dependency (Rehab) - OP – Prof. – SH *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac *** *** *** Chemotherapy - IP & OP - Prof. *** *** *** Chiropractic – Medical - OP - Fac & Prof. *** *** *** Chiropractic – Supplemental - OP - Fac & Prof. *** *** *** Circumcision - OP - Fac & Prof. *** *** *** Diabetic Management Supplies (to include insulin pumps, Glucometer and test strips) *** *** *** Diagnostic Tests (to include contrast medium) - OP - Fac & Prof. *** *** *** Dialysis (to include Hemodialysis and Peritoneal Dialysis) - IP & OP - Prof. *** *** *** Dialysis (to include Hemodialysis and Peritoneal Dialysis) - OP - Fac (including all drugs) *** *** *** DME – (including apnea monitors), Prosthetics (including surgically implanted)/ Orthotics, artificial limbs - IP *** *** *** ~~DME~~DME (including apnea monitors), ~~Ostomy Colostomy Supplies. Prosthetics. Orthotics –~~ Prosthetics (excluding surgically implanted)/ Orthotics, artificial limbs - OP *** *** *** Emergency Room - OP – - Fac *** *** *** Emergency Room - OP – - E.R. Phys. *** *** *** *** All references to the division of financial responsibility have been deleted. Service Description Medical Group Hospital PacifiCare Endoscopic Diagnostic Studies ~~- IP – Prof~~ (Performed without Biopsies) *** *** *** Endoscopic Diagnostic Studies (with Biopsies) *** *** *** Family Planning – Abortions (Elective) - IP and OP – Prof. *** *** *** Family Planning – Abortions (Elective) - IP and OP – Fac *** *** *** ~~Endoscopic Studies~~ Family Planning – Contraceptive Devices – Insertion and Removal - OP ~~– Prof~~ - Prof. *** *** *** Family Planning – All “Legend” Contraceptives (e.g. Norplant/IUD) – OP *** *** *** Family Planning – Contraceptive Devices – Presentation – OP *** *** *** Family Planning – GIFT/ZIFT/IVF - ~~Abortions~~ OP – Fac & Prof. *** *** *** Family Planning – Infertility Procedures/Testing - OP – Prof. *** *** *** Family Planning – Infertility Procedures/Testing - OP – Fac *** *** *** Family Planning ~~- Abortions~~ – Infertility Testing - OP – ~~Prof~~ Prof. *** *** *** Family Planning – Sterilization - ~~Contraceptive Devices - Insertion -~~ IP & OP – ~~Prof~~ Prof. *** *** *** Family Planning ~~- Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription~~ – OP *** *** *** Family Planning - GIFT ZIFT-IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization - IP & OP – Prof *** *** *** Family Planning - Sterilization - IP – Fac *** *** *** Family Planning - – Sterilization - OP – - Fac *** *** *** Fetal Monitoring - – OP - Fac & ~~Prof~~ Prof. *** *** *** Fetal Monitoring – IP - Fac & Prof. *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening (~~Audiologic~~ Audiological Evaluation) – OP *** *** *** Hemodialysis / Dialysis - IP & OP – Prof *** *** *** Hemodialysis Dialysis - OP – Fac (including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP – ~~Prof~~ Prof. *** *** *** Hosp Based Phys Interpretative ~~Serv Incl~~ S?s (to include Radiology & Pathology - IP & OP ~~– Prof~~ - Prof. *** *** *** Hospice Services (Medicare) – IP – Fac & ~~Prof~~ Prof. – SH *** *** *** Hospice Services ~~- Prof~~ – Fac. – CO *** *** *** Hospice Services – Prof. – CO *** *** *** Hospitalization Services (to include Medical and Surgical) - IP – - Fac *** *** *** Immunizations & Inoculations (~~Medically Necessary~~Preventative) – OP *** *** *** Infusion ~~therapy~~ Therapy – OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits AND Not Part of PacifiCare’s Self-Injectable Carve-Out Program (SICOP) – OP *** *** *** Laboratory/Pathology (Diagnostic Only) - – OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof and Prof. *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – ~~Prof~~ Prof. *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - – Prescription – OP *** *** *** Mental Health (Crisis Intervention) - OP – Prof. - ~~Prof –~~ CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP - Fac – CO *** *** *** Mental Health – IP & OP ~~- Prof~~ – Prof. – CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** Mental Health – IP and OP – Fac – CO *** *** *** Mental Health – IP and OP - Fac – SH *** *** *** Mental Health – IP and OP - Prof. – CO *** *** *** Mental Health - IP and OP - Prof. – SH *** *** *** Observation Room - OP – Fac *** *** *** Oral Medications (NOT Part of the Outpatient Pharmacy Benefit) - OP *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP – Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Prof. *** *** *** Ostomy/Colostomy Supplies – IP & OP *** *** *** Out of Area (Urgent and Emergent Non-Referred Covered Services) - IP & OP – Fac *** *** *** Out of Area (Urgent and Emergent Non-Referred Covered Services) - IP & OP – Prof. *** *** *** Physician Services (All Professional Services) - IP & OP - Prof. *** *** *** Radiation Therapy and Related Professional Services - IP & OP - Prof. *** *** *** Radiation Therapy Treatment – IP – Fac. (Includes Free Standing) *** *** *** Radiation Therapy Treatment – OP – Fac. (Includes Free Standing) *** *** *** Radiology (Diagnostic/Theraputic & Nuclear Medicine) - OP *** *** *** Radiology (Diagnostic/Theraputic & Nuclear Medicine) - IP *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M = Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare Allergy - Serum - OP *** *** *** Allergy - Testing & Tx - OP - Prof *** *** *** Ambulance (Air and Ground) - OP *** *** *** Amniocentesis - OP - Fac & Prof *** *** *** Anesthesiology - IP & OP - Prof *** *** *** Autologous Blood Services - OP - Fac & Prof *** *** *** Biofeedback (Medically Necessary) - OP *** *** *** Chemical Dependency (Detox) - IP & OP - Fac *** *** *** Chemical Dependency (Detox) - IP & OP - Prof *** *** *** Chemical Dependency (Rehab) - IP - Fac - CO *** *** *** Chemical Dependency (Rehab) - IP - Fac - SH *** *** *** Chemical Dependency (Rehab) - IP - Prof - CO *** *** *** Chemical Dependency (Rehab) - IP - Prof - SH *** *** *** Chemical Dependency (Rehab) - OP - Fac - CO *** *** *** Chemical Dependency (Rehab) - OP - Fac - SH *** *** *** Chemical Dependency (Rehab) - OP - Prof- CO *** *** *** Chemical Dependency (Rehab) - OP - Prof - SH *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac & Prof *** *** *** *** All references to the division of financial responsibility have been deleted. Service Description Medical Group Hospital Incentive Program PacifiCare Chemotherapy - IP - Prof *** *** *** Chiropractic - Medical - OP - Fac & Prof *** *** *** Chiropractic - Supplemental - OP - Fac & Prof *** *** *** Circumcision - OP - Fac & Prof *** *** *** Diagnostic Tests - OP - Fac & Prof *** *** *** DME – - IP *** *** *** DME, ~~Ostomy~~ Ostomy/Colostomy Supplies. , Prosthetics. /Orthotics – - OP *** *** *** Emergency Room - OP – - Fac *** *** *** Emergency Room - OP – - E.R. Phys. *** *** *** Endoscopic Studies - ~~IP –~~ LP - Prof *** *** *** Endoscopic Studies - OP – - Fac *** *** *** Endoscopic Studies - OP – - Prof *** *** *** Family Planning - Abortions - OP – - Fac *** *** *** Family Planning ~~- Abortions~~ -Abortions - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – - OP *** *** *** Family Planning - ~~GIFT~~ GIFT/ZIFT-/IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – - Fac *** *** *** Family Planning - Infertility Procedures - OP – - Prof *** *** *** Family Planning - Infertility Testing - OP – - Prof *** *** *** Family Planning - Sterilization - IP & OP – - Prof *** *** *** Family Planning - Sterilization - IP – - Fac *** *** *** Family Planning - Sterilization - OP – - Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – - OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – - OP *** *** *** Hearing Screening (Audiologic Evaluation) – - OP *** *** *** Hemodialysis / Dialysis - IP & OP – - Prof *** *** *** Hemodialysis / Dialysis - OP – - Fac (including all drugs) *** *** *** Home Health Care / Homebound Infusion Therapy - OP – - Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – - Prof *** *** *** Hospice Services (Medicare) – - IP – - Fac & Prof – - SH *** *** *** Hospice Services - Prof – - CO *** *** *** Hospitalization Services - IP – - Fac *** *** *** Immunizations & Inoculations (Medically Necessary) – - OP *** *** *** Infusion therapy – - OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – - OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Prof *** *** *** Laboratory/Pathology - ~~IP –~~ LP - Fac *** *** *** Lithotripsy - OP – - Fac *** *** *** Lithotripsy - OP – - Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – - OP *** *** *** Medication - Prescription – - OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof – - CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health ~~Parity~~ Party applies to CO only) *** *** *** *** All references to the division of financial responsibility have been deleted. Service Description Medical Group Hospital Incentive Program PacifiCare Mental Health – - IP & OP - Fac – - CO *** *** *** Mental Health – - IP & OP - Prof – - CO *** *** *** MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits) *** *** *** Mental Health - IP and OP - Fac - CO *** *** *** Mental Health - IP and OP - Fac - SH *** *** *** Mental Health - IP and OP - Prof - CO *** *** *** Mental Health - IP and OP - Prof - SH *** *** *** Observation Room - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Prof *** *** *** Out of Area - IP & OP - Fac *** *** *** Out of Area - IP & OP - Prof *** *** *** Outpatient Surgery - OP - Fac *** *** *** Outpatient Surgery - OP - Prof *** *** *** Physician Services (All Professional Services) - IP & OP - Prof *** *** *** Prosthetics - Surgical Implants - OP *** *** *** Radiation Therapy - IP & OP - Prof *** *** *** Radiation Therapy - OP - Fac and/ or freestanding facility *** *** *** Radiology (Diagnostic Only) - OP - Fac *** *** *** Radiology (Diagnostic Only) - OP - Prof *** *** *** Radiology - LP - Fac *** *** *** Reconstructive Surgery - IP & OP - Prof *** *** *** Reconstructive Surgery - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Prof *** *** *** Skilled Nursing Facility - IP - Fac *** *** *** Sleep Studies - OP *** *** *** TMJ - Evaluation (excludes dental exams/treatment) - OP - Prof *** *** *** Transfusions - OP - Fac *** *** *** Transplants - IP - Fac *** *** *** Transplants - IP - Prof *** *** *** Urgent Care - OP - Fac & Prof *** *** *** Vision - Medical Treatment - OP - Prof *** *** *** Vision - Refraction for Contact Lenses/Frames - OP - Prof *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - CO *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - SH *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M=Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare Allergy - Serum - OP *** *** *** Allergy - Testing & Tx - OP - Prof *** *** *** Ambulance (Air and Ground) - OP *** *** *** Amniocentesis - OP - Fac & Prof *** *** *** Anesthesiology - IP & OP - Prof *** *** *** Autologous Blood Services - OP - Fac & Prof *** *** *** Biofeedback (Medically Necessary) - OP *** *** *** Chemical Dependency (Detox) - IP & OP - Fac *** *** *** Chemical Dependency (Detox) - IP & OP - Prof *** *** *** Chemical Dependency (Rehab) - IP - Fac - CO *** *** *** Chemical Dependency (Rehab) - IP - Fac - SH *** *** *** Chemical Dependency (Rehab) - IP - Prof - CO *** *** *** Chemical Dependency (Rehab) - IP - Prof - SH *** *** *** Chemical Dependency (Rehab) - OP - Fac - CO *** *** *** Chemical Dependency (Rehab) - OP - Fac - SH *** *** *** Chemical Dependency (Rehab) - OP - Prof - CO *** *** *** Chemical Dependency (Rehab) - OP - Prof - SH *** *** *** Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac & Prof *** *** *** Chemotherapy - IP - Prof *** *** *** Chiropractic - Medical - OP - Fac & Prof *** *** *** Chiropractic - Supplemental - OP - Fac & Prof *** *** *** Circumcision - OP - Fac & Prof *** *** *** Diagnostic Tests - OP - Fac & Prof *** *** *** DME – - IP *** *** *** ~~DME, Ostomy~~ DME Ostomy/Colostomy Supplies. , Prosthetics. /Orthotics – - OP *** *** *** Emergency Room - OP – - Fac *** *** *** Emergency Room - OP ~~– E.R. Phys.~~ - Prof *** *** *** Endoscopic Studies - IP – - Prof *** *** *** Endoscopic Studies - OP – - Fac *** *** *** Endoscopic Studies - OP – - Prof *** *** *** Family Planning - Abortions - OP – - Fac *** *** *** Family Planning - Abortions - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – - Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP *** *** *** Family Planning - Contraceptive Devices - Prescription – - OP *** *** *** *** All references to division of financial responsibility have been deleted. Family Planning - ~~GIFT~~ GIFT/ZIFT-/IVF - OP - Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – - Fac *** *** *** Family Planning - Infertility Procedures - OP – - Prof *** *** *** Family Planning - Infertility Testing - OP – - Prof *** *** *** Family Planning - Sterilization - IP & OP – - Prof *** *** *** Family Planning - Sterilization - IP – - Fac *** *** *** Family Planning - Sterilization - OP – - Fac *** *** *** Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – - OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – - OP *** *** *** Hearing Screening (Audiologic Evaluation) – - OP *** *** *** Hemodialysis / Dialysis - IP & OP – - Prof *** *** *** Hemodialysis / Dialysis - OP – - Fac ~~(including all drugs)~~ *** *** *** Home Health Care / ~~Homebound~~ Home Infusion Therapy - OP – - Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP – - Prof *** *** *** Hospice Services (Medicare) – - IP – - Fac & Prof – - SH *** *** *** Hospice Services - IP - Prof – - CO *** *** *** Hospitalization Services - IP – - Fac *** *** *** Immunizations & Inoculations (Medically Necessary) ~~– OP *** *** *** Infusion therapy –~~ - OP *** *** *** Injectables - Not Part of Outpatient Pharmacy Benefits – - OP *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – - Prof *** *** *** Laboratory/Pathology - IP – - Fac *** *** *** Lithotripsy - OP – - Fac *** *** *** Lithotripsy - OP – - Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – - OP *** *** *** Medication - Prescription – - OP *** *** *** Mental Health (Crisis Intervention) - OP - Prof ~~– CO *** *** *** MENTAL HEALTH: AB88 Benefits (Mental Health Parity applies to CO only) *** *** *** Mental Health – IP & OP~~ - ~~Fac –~~ CO *** *** *** Mental Health – - IP ~~& OP~~ - ~~Prof –~~ Fac - CO *** *** *** ~~MENTAL HEALTH: Secure Horizons and Commercial~~ Mental Health - IP - Fac - SH *** *** *** Mental Health - IP - Prof - CO *** *** *** Mental Health - IP - Prof - CO *** *** *** Mental Health - OP - Fac - CO *** *** *** Mental Health - OP - Fac - SH *** *** *** Mental Health - OP - Prof - CO *** *** *** Mental Health - OP - Prof - SF *** *** *** Observation Room - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Fac *** *** *** Oral Surgery / Dental Services - Accident & Injury Only - OP - Prof *** *** *** Out of Area - IP & OP - Fac *** *** *** Out of Area - IP & OP - Prof *** *** *** Outpatient Surgery - OP - Fac *** *** *** Outpatient Surgery - OP - Prof *** *** *** Physician Services (~~non AB88 Benefits~~All Professional Services) - IP & OP - Prof *** *** *** Prosthetics - Surgical Implants - OP *** *** *** Radiation Therapy - IP & OP - Prof *** *** *** Radiation Therapy - OP - Fac *** *** *** Radiology (Diagnostic Only) - OP - Fac *** *** *** Radiology (Diagnostic Only) - OP - Prof *** *** *** Radiology - IP - Fac *** *** *** Reconstructive Surgery - IP & OP - Prof *** *** *** Reconstructive Surgery - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Fac *** *** *** Rehabilitation - Cardiac/OT/PT/RT/ST - OP - Prof *** *** *** Skilled Nursing Facility - IP - Fac *** *** *** Sleep Studies - OP *** *** *** *** All references to ~~the~~ division of financial responsibility have been deleted.. TMJ - Evaluation (excludes dental exams/treatment) - OP - Prof *** *** *** Transfusions - OP - Fac *** *** *** Transplants - IP - Fac *** *** *** Transplants - IP - Prof *** *** *** Urgent Care - OP - Fac & Prof *** *** *** Vision - Medical Treatment - OP - Prof *** *** *** Vision - Refraction for Contact Lenses/Frames - OP - Prof *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - CO *** *** *** Vision Care Materials - Contact Lenses/Frames (non-cataract) - OP - SH *** *** *** *** All references to division of financial responsibility have been deleted. 0000 Xxxxxxx Xxxxxx Cypress, California 00000-0000 Tel (000) 000-0000 July 11, 2001 Xxx Xxxxxx, CEO SENT VIA FACSIMILE: 000-000-0000 Gateway Physicians Medical Associates 000 Xxxxx Xxxxxx Xxxxxx Xxxxxxx, XX 00000 Dear Raj, In follow up to our previous discussions about the implementation of Age/Sex/Benefit Adjusted Capitation for Gateway Physicians Medical Associates – Placentia Xxxxx & United Western Medical Center, attached please find our Rate Grid that will be effective 7/1/2001. The calculation is based on Membership distribution as of July, 2001. The grid for Gateway 16206 ties to Gateway – Placentia, and the grid for 16210 ties to Gateway – United Western Medical Center. Effective 8/1/2001 capitation will be paid at the schedule attached. Should you have any questions, please give me a call at 000-000-0000. Yours truly, /s/ Xxx Xxxxxx-Xxxxxxx Xxx Xxxxxx-Xxxxxxx Contract Manager PacifiCare of California PacifiCare of California - Commercial Gateway (#16206)

Appears in 1 contract

Samples: Ipa Services Agreement (Prospect Medical Holdings Inc)

Division of Financial Responsibility. ~~KEY M=~~ KEY: M - Opt-~~Out~~ out to Medicare benefit for ~~Hosptee~~ Hospice Service Description Medical Group Hospital Incentive Program PacifiCare ~~Diagnostic Tests~~ Allergy - ~~OP - Fac & Prof *** *** *** DME – IP *** *** *** DME, Ostomy Colostomy Supplies. Prosthetics. Orthotics~~ Serum – OP *** *** *** ~~Emergency Room~~ Allergy - ~~OP – Fac *** *** *** Emergency Room - OP – E.R. Phys. *** *** *** Endoscopic Studies - IP – Prof *** *** *** Endoscopic Studies - OP – Fac *** *** *** Endoscopic Studies~~ Testing & Tx - OP – Prof *** *** *** Family Planning - Abortions - OP – Fac *** *** *** Family Planning - Abortions - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Insertion - OP – Prof *** *** *** Family Planning - Contraceptive Devices - Non-Rx Ambulance (~~eg. Norplant/IUD~~Air and Ground) ~~- OP *** *** *** Family Planning - Contraceptive Devices - Prescription~~ – OP *** *** *** ~~Family Planning - GIFT ZIFT-IVF~~ Amniocentesis - OP - – Fac & Prof *** *** *** Family Planning - Infertility Procedures - OP – Fac *** *** *** Family Planning - Infertility Procedures - OP – Prof *** *** *** Family Planning - Infertility Testing - OP – Prof *** *** *** Family Planning - Sterilization Anesthesiology - IP & OP – Prof *** *** *** ~~Family Planning~~ Autologous Blood Services - ~~Sterilization - IP~~ OP – Fac & Prof *** *** *** ~~Family Planning~~ Biofeedback (Medically Necessary) – OP *** *** *** Chemical Dependency (Detox) - ~~Sterilization -~~ IP & OP – Fac *** *** *** ~~Fetal Monitoring - OP - Fac & Prof *** *** *** Health Education – OP *** *** *** Health Eval/Physical *** *** *** Hearing Aids/Molds – OP *** *** *** Hearing Screening~~ Chemical Dependency (~~Audiologic Evaluation~~Detox) ~~– OP *** *** *** Hemodialysis / Dialysis~~ - IP & OP – Prof *** *** *** ~~Hemodialysis Dialysis~~ Chemical Dependency (Rehab) - OP IP - Fac – ~~Fac (including all drugs)~~ CO *** *** *** ~~Home Health Care / Homebound Infusion Therapy - OP – Prof *** *** *** Hosp Based Phys Interpretative Serv Incl Radiology & Pathology~~ Chemical Dependency (Rehab) - IP ~~& OP – Prof *** *** *** Hospice Services (Medicare) – IP –~~ - Fac ~~& Prof~~ – SH *** *** *** ~~Hospice Services~~ Chemical Dependency (Rehab) - IP - Prof – CO *** *** *** ~~Hospitalization Services~~ Chemical Dependency (Rehab) - IP - Prof – ~~Fac~~ SH *** *** *** ~~Immunizations & Inoculations~~ Chemical Dependency (~~Medically Necessary~~Rehab) - OP - Fac – OP CO *** *** *** ~~Infusion therapy~~ Chemical Dependency (Rehab) - OP - Fac – OP SH *** *** *** ~~Injectables - Not Part of Outpatient Pharmacy Benefits – OP *** *** *** Laboratory/Pathology~~ Chemical Dependency (Diagnostic Only) - OP – Fac *** *** *** Laboratory/Pathology (Diagnostic Only) - OP – Prof *** *** *** Laboratory/Pathology - IP – Fac *** *** *** Lithotripsy - OP – Fac *** *** *** Lithotripsy - OP – Prof *** *** *** Med/Surg Supplies (casts, splints, bandages) - Office – OP *** *** *** Medication - Prescription – OP *** *** *** Mental Health (Crisis InterventionRehab) - OP - Prof – CO *** *** *** ~~MENTAL HEALTH: AB88 Benefits~~ Chemical Dependency (~~Mental Health Parity applies to CO only~~Rehab) - OP - Prof – SH *** *** *** ~~Mental Health – IP &~~ Chemotherapy (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac ~~– CO~~ & Prof *** *** *** ~~Mental Health~~ Chemotherapy - IP – ~~IP & OP -~~ Prof ~~– CO~~ *** *** *** ~~MENTAL HEALTH: Secure Horizons and Commercial (non AB88 Benefits)~~ Chiropractic - Medical - OP - Fac & Prof *** *** *** Chiropractic - Supplemental - OP - Fac & Prof *** *** *** Circumcision - OP - Fac & Prof *** *** *** *** All references to the division of financial responsibility have been deleted.

Appears in 1 contract

Samples: Services Agreement (Prospect Medical Holdings Inc)

Common use of Division of Financial Responsibility Clause in Contracts