HEALTH CARE MANAGEMENT SERVICES Sample Clauses

HEALTH CARE MANAGEMENT SERVICES. A Member is entitled to benefits for Covered Services under this Agreement, subject to exclusions, conditions and limitations of this Agreement, and subject to Health Care Management Services administered by the Plan. When Precertification/Certification, as set forth in this Agreement, is required, Medical Necessity and Appropriateness for Covered Services will be determined prior to the Covered Service being rendered. However, when Precertification/Certification is not required, the Plan may determine that a Covered Service was not Medically Necessary and Appropriate after the Covered Service has been rendered. When a Member seeks Covered Services from an Out-of-Network Provider or outside the Network Service Area, the Member is required to call the Precertification toll-free number on the back of his/her Identification Card, prior to the receipt of the Covered Services, to determine what, if any, Precertification requirements they must follow. 1. Pre-Admission Certification a. In-Area Network Services b. Out-of-Area Network Services In the event of a proposed Inpatient stay to a Network Facility Provider located Out- of-Area, for other than an emergency, it shall be the responsibility of the Network Facility Provider to contact the Plan prior to a proposed admission to obtain Precertification of the admission. In addition, the Member must contact the Plan to confirm the Plan’s determination of Medical Necessity and Appropriateness prior to the admission. i) If Precertification for a Medically Necessary and Appropriate Inpatient admission has been obtained, as required under this Agreement, benefits will be paid in accordance with this Agreement. ii) If a Member elects to be admitted after receiving written notification from the Plan that any portion of the proposed admission is not Medically Necessary and Appropriate, the Member will be financially responsible for all charges associated with care that has been determined not to be Medically Necessary and Appropriate. iii) If a Network Facility Provider DOES NOT CONTACT the Plan for Precertification, as required under this Agreement, any claim for benefits will be reviewed for Medical Necessity and Appropriateness. It is important that the Member confirm the Plan’s determination of Medical Necessity and Appropriateness, otherwise if such admission is determined not to be Medically Necessary and Appropriate, no benefits will be provided and the Member will be financially responsible for the difference betw...

HEALTH CARE MANAGEMENT SERVICES a program which integrates all activity related to managing a Member’s medical care from the time that an admission, surgical or diagnostic procedure, or certain services become necessary. The program consists of any applicable pre-admission Certification, Admission Certification of Emergency Admissions, Outpatient Procedure or Covered Service Precertification, Continued Stay Review, Discharge Planning, and Individual Case Management.

HEALTH CARE MANAGEMENT SERVICES. A complete Health Care Management Service (HMS) Program requires review prior to non-emergency and non-delivery related admissions to determine the medical necessity and appropriateness for the proposed admission or services.

HEALTH CARE MANAGEMENT SERVICES. The receipt of Covered Services is subject to all terms, definitions and exclusions specified in this Agreement. Except as provided herein, benefits are not provided for Out-of-Network Services. Specific payment provisions are outlined in SECTION SB - SCHEDULE OF BENEFITS of this Agreement, as well as in this Section. Members may contact the Plan at the toll-free telephone number or the website appearing on the back of the Member’s Identification Card to locate a Network Provider or to obtain a Provider Directory.

HEALTH CARE MANAGEMENT SERVICES. (a) During the Term hereof, CareAdvantage shall provide to Blue Cross, when requested by Blue Cross, certain care management services as more particularly specified herein and in Attachment I attached hereto and incorporated herein by reference for the purpose of assisting Blue Cross in the proper and effective administration of its health benefit programs (underwritten and administered) and in the reduction of inappropriate claims liability for its underwritten and administered health benefit plans. (b) During the Term, the services provided by CareAdvantage under this Agreement shall be supervised by Stephan D. Deutsch, M.D. or another physician with similar qualificationx xxxxxxxd by Blue Cross, which approval shall not be unreasonably withheld; provided, however, that during the term hereof, Blue Cross may withdraw its approval of any physician providing supervisory services hereunder if Blue Cross reasonably determines that the supervisor is not providing effective supervision in a manner which is compatible with Blue Cross procedures, whereupon CareAdvantage shall remedy the supervisory problem to the satisfaction of Blue Cross or replace such supervisor with a supervisor approved by Blue Cross, with such action to be taken within ninety (90) days of a written request from Blue Cross. Dr. Deutsch (or such other physician) shall spend half time at Blue Cross in order to properly supervise the provision of such services. (c) In fulfilling its responsibilities under this Agreement, CareAdvantage shall provide at least three and one-half medical management physicians on a full-time equivalent basis: (i) one of which shall serve as the Medical Director for Blue Cross; (ii) one-half of which shall act as a Director responsible for the coordination of the provision of services which CareAdvantage shall provide in accordance with the terms of Section 2(b); (iii) two of which shall serve as Associate Medical Director and Physician Adviser to conduct utilization review and case reviews for Blue Cross as required under the terms of this Agreement; and (iv) such other physicians, nurses, experts, and other personnel, which individuals shall be employed by, or under contract to, CareAdvantage, as shall be necessary for CareAdvantage to perform its obligations under this Agreement. The Medical Director, Associate Medical Directors, and other physicians, individuals and/or entities employed by, or under contract to CareAdvantage to provide services under this Agree...