G MEDICAL NECESSITY Sample Clauses

G MEDICAL NECESSITY. The Contractor shall cover medically necessary services, as defined in this Contract and the Family Access to Medical Insurance Security (FAMIS) Plan as amended and as further defined by written Department policies (including agreements, statements, provider manuals, FAMIS memorandums, instructions, or memoranda of understanding) applicable State and Federal regulations, guidelines, transmittals, and procedures, and in accordance with industry standards of practice. The actual provision of any service is subject to the professional judgment of the Contractor’s providers as to the medical necessity of the service, except in situations in which the Contractor must provide services ordered by the Department pursuant to an appeal from the Contractor’s grievance process or an appeal directly to the Department by the parent or guardian of a member or for emergency services as defined in this Contract. Decisions to provide authorized medical services required by this Contract shall be based solely on medical necessity and appropriateness. Disputes between the Contractor and members about medical necessity may be appealed to the external review organization by the member or the member’s representative after completing the Contractor’s appeal process. In no case shall the Contractor establish more restrictive benefit limits for medically necessary services than those established by Medicaid. The Contractor shall manage service utilization through utilization review and prior authorization, but not through the establishment of benefit limits for medically necessary services that are more restrictive than those established by Medicaid. The Contractor shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. Coverage decisions that depend upon prior authorization and/or concurrent review to determine medical necessity must be in accordance with industry of practice and shall be supervised by qualified medical professionals and completed within a reasonable period of time after receipt of all necessary information. The Contractor shall assume responsibility for all covered medical conditions of each member as of the effective date of coverage under the Contract, regardless of the date on which the condition arose. The Contractor shall cover all pre-existing conditions.
Sample 1
AutoNDA by SimpleDocs

Related to G MEDICAL NECESSITY

  • Medical Necessity We Cover benefits described in this Contract as long as the dental service, procedure, treatment, test, device, or supply (collectively, “service”) is Medically Necessary e.g. orthodontia. The fact that a Provider has furnished, prescribed, ordered, recommended, or approved the service does not make it Medically Necessary or mean that We have to Cover it. We may base Our decision on a review of: • Your dental records; • Our dental policies and clinical guidelines; • Dental opinions of a professional society, peer review committee or other groups of Physicians; • Reports in peer-reviewed dental literature; • Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; • Professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; • The opinion of health care professionals in the generally-recognized health specialty involved; • The opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: • They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; • They are required for the direct care and treatment or management of that condition; • Your condition would be adversely affected if the services were not provided; • They are provided in accordance with generally-accepted standards of dental practice; • They are not primarily for the convenience of You, Your family, or Your Provider; • They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results; • When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. See the Utilization Review and External Appeal sections of this Contract for Your right to an internal Appeal and external appeal of Our determination that a service is not Medically Necessary.

  • Personal Necessity 1.1 Unit members may use a maximum of seven (7) days of accumulated sick leave for personal necessity. Personal Necessity Leave shall be limited to circumstances that are serious in nature and that the employee cannot reasonably be expected to disregard, that necessitate immediate attention and cannot be taken care of after work hours or on weekends.

  • CULTURAL DIVERSITY The Cultural Diversity Requirement generally does not add units to a student's program. Rather, it is intended to be fulfilled by choosing courses from the approved list that also satisfy requirements in other areas of the student’s program; the exception is that Cultural Diversity courses may not satisfy Culture and Language Requirements for B.S. students. For example, Anthropology 120 can fulfill (3) units of the Behavioral Science requirement and (3) units of the Cultural Diversity requirement. This double counting of a class may only be done with the Cultural Diversity requirement. Courses in Cultural Diversity may be taken at the lower-division or upper-division level. U . S . H I S T O R Y I N S T I T U T I O N A L R E Q U I R E M E N T HIS 120, 121, 270, 275

  • Stewardship The efficient and effective management of the public funds that have been entrusted to the FHWA.

  • Pressing Necessity An Employee shall be granted leave without pay for pressing necessity. Pressing necessity shall be defined as a sudden or unusual occurrence that could not, by the exercise of reasonable judgement, have been foreseen by the Employee and which requires the immediate attention of the Employee. The Employee may elect to use any entitlement to time off such as vacation, public holiday or earned time.

  • Cultural cooperation 1. The aims of cultural cooperation will be: (a) to build on existing agreements or arrangements already in place for cultural cooperation; and (b) to promote information and cultural exchanges between the Parties. 2. The Parties will encourage and facilitate, as appropriate, the following activities, including, but not limited to: (a) dialogue on cultural policies and promotion of local culture; (b) exchange of cultural events and promote awareness of artistic works; (c) exchange of experience in conservation and restoration of national heritage; (d) exchange of experience on management for the arts; (e) protecting archaeological monuments and cultural heritage; (f) having a consultation mechanism between the Parties' culture authorities; and (g) cooperation in the audio-visual field, mainly coproduction and training programs in this sector and means of communication, including training, development and distribution activities.

  • Cultural Competence A. The CONTRACTOR shall participate in the State's efforts to promote the delivery of services in a culturally competent manner to all beneficiaries, including those with limited English proficiency and diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation or gender identity. (42 C.F.R. § 438.206(c)(2).)

  • Recognition of Union Stewards and Grievance Committee In order to provide an orderly and speedy procedure for the settling of grievances, the Employer acknowledges the rights and duties of the Union Stewards. The Xxxxxxx shall assist any Employee, which the Xxxxxxx represents, in preparing and presenting her grievance in accordance with the grievance procedure.

  • Personal Necessity Leave 13.2.1 A maximum of seven (7) days of sick leave may be used by an employee in any school year for personal necessity, for the following purposes:

  • Behavioral Health Behavioral health services, with the exception of Medicaid Rehabilitation Option (MRO) and 1915(i) services, are a covered benefit under the Hoosier Healthwise program. The Contractor shall be responsible for managing and reimbursing all such services in accordance with the requirements in this section. In furnishing behavioral health benefits, including any applicable utilization restrictions, the Contractor shall comply with the Mental Health Parity and Additions Equity Act (MHPAEA). This includes, but is not limited to:  Ensuring medical management techniques applied to mental health or substance use disorder benefits are comparable to and applied no more stringently than the medical management techniques that are applied to medical and surgical benefits.  Ensuring compliance with MHPAEA for any benefits offered by the Contractor to members beyond those otherwise specified in this Scope of Work.  Making the criteria for medical necessity determinations for mental health or substance use disorder benefits available to any current or potential members, or contracting provider upon request.  Providing the reason for any denial of reimbursement or payment with respect to mental health or substance use disorder benefits to members.  Providing out-of-network coverage for mental health or substance use disorder benefits when made available for medical and surgical benefits. The Contractor shall assure that behavioral health services are integrated with physical care services, and that behavioral health services are provided as part of the treatment continuum of care. The Contractor shall develop protocols to:  Provide care that addresses the needs of members in an integrated way, with attention to the physical health and chronic disease contributions to behavioral health;  Provide a written plan and evidence of ongoing, increased communication between the PMP, the Contractor and the behavioral health care provider; and  Coordinate management of utilization of behavioral health care services with MRO and 1915(i) services and services for physical health.

Time is Money Join Law Insider Premium to draft better contracts faster.