How Non-network Providers Are Paid If you receive care from a non-network provider, you are responsible for paying all charges for the services you received. You may submit a claim for reimbursement of the payments you made. For the limited circumstances listed below, your copayment and deductible will apply at the network level of benefits: • emergency care (emergency room, urgent care and ambulance services); • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; • covered healthcare services are rendered by a non-network provider at a network facility outside of your control; • otherwise, as required by law. For those circumstances where we cover services from a non-network provider, we reimburse you or the non-network provider, less any copayments and deductibles, up to the lesser of: • our allowance; • the non-network provider’s charge; or • the benefit limit. You are responsible for the deductible, if one applies, and the copayment, as well as any amount over the benefit limit that applies to the service you received. You are liable for the difference between the amount that the non-network provider bills and the payment we make for covered healthcare services. Generally, we send reimbursement to you, but we reserve the right to reimburse a non-network provider directly. We reimburse non-network provider services using the same guidelines we use to pay network providers. Generally, our payment for non-network provider services will not be more than the amount we pay for network provider services. If an allowance for a specific covered healthcare service cannot be determined by reference to a fee schedule, reimbursement will be based upon a calculation that reasonably represents the amount paid to network providers. For emergency services, we reimburse non- network providers, in accordance with R.I. Gen. Laws § 27-18-76, the greater of our allowance, our usual guidelines for paying non-network providers, or the amount that would be paid under Medicare, less any copayments or deductibles. Payments we make to you are personal. You cannot transfer or assign any of your right to receive payments under this agreement to another person or organization, unless the R.I. General Law §27-20-49 (Dental Insurance assignment of benefits) applies. For information about network authorization requests to seek covered healthcare services from a non-network provider when the covered healthcare service cannot be provided by a network provider, please see Network Authorization in Section 5.
Operations Manager Secondary Contact Email Please enter a valid email address that will definitely reach the Secondary Contact. xxxxx@xxxxxxxxxxxxxxxxxx.xxx Secondary Contact Phone Numbers only, no symbols or spaces (Ex. 8668398477). The system will auto-populate your entry with commas once submitted which is appropriate and expected (Ex. 8,668,398,477). Please provide the accurate and current phone number where the individual who will be secondarily responsible for all TIPS matters and inquiries for the duration of the contract can be reached directly. 0000000000 Secondary Contact Fax Numbers only, no symbols or spaces (Ex. 8668398477). The system will auto-populate your entry with commas once submitted which is appropriate and expected (Ex. 8,668,398,477). No response Secondary Contact Mobile Numbers only, no symbols or spaces (Ex. 8668398477). The system will auto-populate your entry with commas once submitted which is appropriate and expected (Ex. 8,668,398,477). 1 7 4053957859 Administration Fee Contact Name Please identify the individual who will be responsible for all payment, accounting, and other matters related to Vendor's TIPS Administration Fee due to TIPS for the duration of the contract. Xxxxx Xxxxxx Administration Fee Contact Email Please enter a valid email address that will definitely reach the Administration Fee Contact. 1 9 xxxxx@xxxxxxxxxxxxxxxxxx.xxx Administration Fee Contact Phone Numbers only, no symbols or spaces (Ex. 8668398477). The system will auto-populate your entry with commas once submitted which is appropriate and expected (Ex. 8,668,398,477). 2 0 4057954149
Manager 5.1. Rules relating to the rights, duties and responsibilities of the Managers shall be governed by the Act. Such provisions are hereinafter incorporated into this Agreement by reference. Without limiting the generality of the foregoing, the Manager shall have the powers set forth in Paragraph 5.3 below.
Association-Management Committee There shall be an Association-Management Committee comprised of two (2) representatives of the parties. The Committee shall meet quarterly, unless otherwise mutually agreed. Agenda items to be discussed shall be exchanged in writing at least five calendar days prior to the meeting. Meetings of this Committee will be to discuss matters of mutual concern, matters relating to nursing, professional practice, scheduling and work load issues. The Committee shall promote and provide for effective and meaningful communication. The parties agree Self Scheduling is appropriate subject matter to discuss in this forum.
Executive Management The PH-MCO must include in its Executive Management structure: • A full-time Administrator with authority over the entire operation of the PH-MCO. • A full-time HealthChoices Program Manager to oversee the operation of the Agreement, if different than the Administrator. • A full-time Medical Director who is a current Pennsylvania-licensed physician. The Medical Director must be actively involved in all major clinical program components of the PH-MCO and directly participates in the oversight of the SNU, QM Department and UM Department. The Medical Director and his/her staff/consultant physicians must devote sufficient time to the PH-MCO to provide timely medical decisions, including after-hours consultation, as needed. • A full-time Pharmacy Director who is a current Pennsylvania-licensed pharmacist. The Pharmacy Director oversees the outpatient drug management and serves on the PH-MCO P&T Committee. • A Dental Director who is a current Pennsylvania-licensed Doctor of Dental Medicine or Doctor of Dental Surgery. The Dental Director may be a consultant or employee but must be available at a minimum of 30 hours per week. The Dental Director must be actively involved in all program components related to dental services including, but not limited to, dental provider recruitment strategy, assessment of dental network adequacy, providing oversight and strategic direction in the quality of dental services provided, actively engaged in the development and implementation of quality initiatives, and monitor the performance of the dental benefit manger if dental benefits are subcontracted. A full-time Director of Quality Management who is a Pennsylvania- licensed RN, physician or physician's assistant or is a Certified Professional in Healthcare Quality by the National Association for Healthcare Quality Certified in Healthcare Quality and Management by the American Board of Quality Assurance and Utilization Review Providers. The Director of Quality Management must be located in Pennsylvania and have experience in quality management and quality improvement. Sufficient local staffing under this position must be in place to meet QM Requirements. The primary functions of the Director of Quality Management position are: • Evaluate individual and systemic quality of care • Integrate quality throughout the organization • Implement process improvement • Resolve, track, and trend quality of care complaints • Develop and maintain a credentialed Provider network • A full-time CFO to oversee the budget and accounting systems implemented by the PH-MCO. The CFO must ensure the timeliness and accuracy of all financial reports. The CFO shall devote sufficient time and resources to responsibilities under this Agreement. • A full-time Information Systems Coordinator, who is responsible for the oversight of all information systems issues with the Department. The Information Systems Coordinator must have a good working knowledge of the PH-MCO's entire program and operation, as well as the technical expertise to answer questions related to the operation of the information system. • These full time positions must be solely dedicated to the PA HealthChoices Program.
SUPERVISORY PERSONNEL All supervisors and foremen shall be excluded from the bargaining unit and will not perform any work which falls within the scope of this Agreement. When supervisors and foremen are appointed, a notice to that effect will be posted and maintained on a bulletin board.
Labour Management Committee (a) Where the parties mutually agree that there are matters of mutual concern and interest that would be beneficial if discussed at a Labour-Management Committee Meeting during the term of this Agreement, the following shall apply.
Operations Fire An “Operations Fire” is a fire caused by Purchaser’s Operations other than a Neg- ligent Fire. Forest Service, except as provided in B7.3, shall use cooperative deposits under B4.218 to perform fire sup- pression activities on Operations Fires. Xxxxxxxxx agrees to reimburse Forest Service for such cost for each Opera- tions Fire, subject to a maximum of the dollar amount stated in A14. The cost of Purchaser’s actions, supplies, and equipment on any such fire provided pursuant to B7.3, or otherwise at the request of Forest Service, shall be credited toward such maximum. If Purchaser’s actual cost exceeds Purchaser’s obligation stated in A14, Forest Service shall reimburse Purchaser for the excess.
Management Team Subject to any approval or consulting rights of the --------------- Joint Operations Committee, Manager shall engage or designate one or more individuals experienced in dental group management and direction, including, but not limited to, an administrator, who will be responsible for the overall administration of the Practice including day-to-day operations and strategic development activities.
Operating Committee the Consortium’s managing body, composed of representatives of the Manager and the Contractors, pursuant to Annex XI.
