Lease and DHA Property Care Services. This is an agreement by which the Lessor:
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Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
Procurement and Property Management Standards The parties to this Agreement shall adhere to the procurement and property management standards established in 2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, and to the Texas Uniform Grant Management Standards. The State must pre-approve the Local Government’s procurement procedures for purchases to be eligible for state or federal funds.
Emergency Care Services If you experience a medical emergency while traveling outside our service area, go to the nearest emergency or urgent care facility. When you receive Out-of-Area covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for the Out-of-Area Covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of: • the billed charges for your Out-of-Area covered healthcare services; or • the negotiated price that the Host Blue makes available to us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.
PUBLIC WORKS AND BUILDING SERVICES CONTRACTS Work being done under a resulting Authorized User Agreement may be subject to the prevailing wage rate provisions of the New York State Labor Law. Such work will be identified by the Authorized User within the RFQ. See “Prevailing Wage Rates – Public Works and Building Services Contracts’ in Appendix B, Clause 10, OGS General Specifications. Any federal or State determination of a violation of any public works law or regulation, or labor law or regulation, or any OSHA violation deemed "serious or willful" may be grounds for a determination of vendor non-responsibility and rejection of proposal. The Prevailing Wage Case Number for this Contract is PRC# 2014011745. The Prevailing Wage Rates for various occupations and General Provisions of Laws Covering Workers on Article 8 Public Work Contract can be accessed at the following NYS Department of Labor website: xxxxx://xxxxxxxxxxxx.xxxxx.xx.xxx/wpp/xxxxXxxxXxxxxxx.xx?method=showIt Insert PRC# 2014011745 in the box provided and click Submit. Click Wage Schedule located underneath the main header of this page. The PDF file may be searched to obtain the Prevailing Wage Rate for a specific occupation. SHORT TERM EXTENSION In the event a replacement Contract has not been issued, any Contract let and awarded hereunder by the State, may be extended unilaterally by the State for an additional period of up to 3 months upon notice to the Contractor with the same terms and conditions as the original Contract including, but not limited to, prices and delivery requirements. With the concurrence of the Contractor, the extension may be for a period of up to 6 months in lieu of 3 months. However, this extension terminates should the replacement Contract be issued in the interim. PROCUREMENT INSTRUCTIONS Authorized Users should refer to the documents attached as Appendix G – Processes and Forms Templates for specific instructions on the usage of this Contract. OGS reserves the right to unilaterally make revisions, changes, additions and/or updates to the documents attached as Appendix G - Processes and Forms Templates without processing a formal amendment and/or modification. SPECIFICATIONS During the term of the Contract, the Authorized User may request Product specifications for particular items that have been included by the Contractor in its Pricing Pages. These specifications will be provided by the Contractor at no cost.
PREVAILING WAGE RATES - PUBLIC WORKS AND BUILDING SERVICES CONTRACTS If any portion of work being Bid is subject to the prevailing wage rate provisions of the Labor Law, the following shall apply:
Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.
Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.
Hospice Care If you have a terminal illness and you agree with your physician not to continue with a curative treatment program, this plan covers hospice care services received in your home, in a skilled nursing facility, or in an inpatient facility.
COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.
Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered
