EXCLUSIONS FROM COVERED SERVICES); Clause Samples
EXCLUSIONS FROM COVERED SERVICES);. Fertility drugs;
EXCLUSIONS FROM COVERED SERVICES);. In addition to those services and benefits excluded from Covered Services by 89 111. Adm. Code, Part 140, as amended from time to time, the following services and benefits shall NOT be included as Covered Services:
(1) Dental services;
(2) Pharmacy services provided by a pharmacy;
(3) Mental health clinic services as provided through a community behavioral health provider as identified in 89 111. Adm. Code 140.452 and 140.454 and further defined in 59 111. Adm. Code, Part 132 "Medicaid Community Mental Health Services Program."
(4) Subacute alcoholism and substance abuse treatment services as provided through a community behavioral health provider as identified in 89 111. Adm. Code 148.340(a) and farther defined in 77 111. Adm. Code 2090.
(5) Routine examinations to determine visual acuity and the refractive state of the eye, eyeglasses, other devices to correct vision, and any associated supplies and equipment. The Contractor shall refer Enrollees needing such services to Providers participating in the HFS Medical Programs who are able to provide such services, or to a central referral entity that maintains a list of such Providers.
(6) Nursing facility services, or equivalent care provided at home because a skilled nursing facility is unavailable, beginning on the ninety-first (91st) day of service in a calendar year;
(7) Services provided in an Intermediate Care Facility for the Mentally Retarded/Developmcntally Disabled and services provided in a nursing facility to mentally retarded or developmentally disabled Participants;
(8) Early intervention services, including case management, provided pursuant to the Early Intervention Services System Act (325 ILCS 20 et seq.);
(9) Services provided through school-based clinics as such clinics are defined by the Department;
(10) Services provided through local education agencies that are enrolled with the Department under an approved individual education plan (IEP);
(11) Services funded through the Juvenile Rehabilitation Services Medicaid Matching Fund;
(12) Services that are experimental and/or investigational in nature;
(13) Services provided by a non-Affiliated Provider and not authorized by the Contractor, unless this Contract specifically requires that such services be covered;
(14) Services that are provided without first obtaining a required referral or prior authorization as set forth in the Enrollee handbook;
(15) Medical and/or surgical services provided solely for cosmetic purposes; and
(16) Diagnos...
EXCLUSIONS FROM COVERED SERVICES);. This Contract expressly excludes expenses for the following services. These Exclusions are in addition to any Exclusions specified in Part IX. COVERED SERVICE CATEGORIES and any Limitations specified in Part X. LIMITATIONS OF COVERED SERVICES.
EXCLUSIONS FROM COVERED SERVICES);. Continued therapy is only Medically Necessary when prescribed by a Physician in order to significantly improve, develop or restore physical functions that have been lost or impaired. Using additional diagnoses to obtain additional therapy for the same Condition is not considered Medically Necessary. Once maximum therapeutic benefit has been achieved, and there is no longer any progression, or a home exercise program could be used for any further gains, continuing supervised therapy is not considered Medically Necessary. Therapy for persons whose Condition is neither regressing nor improving is considered not Medically Necessary. Therapy for asymptomatic persons or in persons without an identifiable clinical Condition is considered not Medically Necessary.
EXCLUSIONS FROM COVERED SERVICES);. This Contract expressly excludes expenses for the following services. These Exclusions are in addition to any Exclusions specified in Part IX. COVERED SERVICE CATEGORIES and any Limitations specified in Part X. LIMITATIONS OF COVERED SERVICES.
11.1 General Exclusions include expenses for:
a. services received prior to your Effective Date or after the date your coverage terminates;
b. services not within the service categories described in Part IX. COVERED SERVICE CATEGORIES and any amendments attached hereto, unless such services are specifically required to be covered by applicable law;
c. services provided by a Physician or other Health Care Provider related to you by blood or marriage;
d. services beyond the scope of practice authorized for a Health Professional under applicable state law;
e. services which are not Medically Necessary as defined in this Contract and as determined by AvMed. The ordering of a service by a Health Care Provider does not in itself make such service Medically Necessary or a Covered Service;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred or resulted from you being under the influence of alcoholic beverages, any chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled under Chapter 893, Florida Statutes (or, with respect to such statutory provisions, any successor statutory provisions). Notwithstanding, this Exclusion shall not apply to the use of any Prescription Medication by you if such medication is taken on the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with:
i. medical care connected with Armed Forces service (for both sickness and injury); services received at military or government facilities; services received to treat an injury arising out of your service in the Armed Forces, Reserves or National Guard; or
ii. your participation in, or commission of, any act punishable by law as a misdemeanor or felony whether or not you are charged or convicted, or which constitutes riot or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member demonstrates that an injury resulted from an a...
EXCLUSIONS FROM COVERED SERVICES);. In addition to those services and benefits excluded from Covered Services by 89 Ill. Adm. Code, Part 140, as amended from time to time, the following services