Medically Necessary and Appropriate Sample Clauses

Medically Necessary and Appropriate. “Medically Necessary and Appropriate” means that the benefits under this Agreement for services received from a Network provider will be provided only when and so long as such services are determined by the Plan or its designated agent to be: 1) appropriate for the symptoms and diagnosis or treatment of the member’s condition, illness, disease or injury; and 2) provided for the diagnosis, of the direct care and treatment of the member’s condition, illness, disease or injury; and 3) in accordance with standards of good medical practice; and 4) not primarily for the convenience of the member, or the member’s physician and/or other provider; and 5) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as a bed patient due to the nature of the services rendered or the member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers, Highmark managed care facility providers, network professional providers and PremierBlue Shield professional providers (out-of-area) will accept this determination of medical necessity. Out-of-network providers may not accept this determination and may xxxx the member for services determined not to be Medically Necessary and Appropriate. See the Agreement for further explanation.
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Medically Necessary and Appropriate. “Medically necessary and appropriate” means that the benefits under the Agreement for services received from a network provider will be provided only when and so long as such services are determined by the Plan to be: a) appropriate for the symptoms and diagnosis or treatment of the member’s condition, illness, disease or injury; and b) provided for the diagnosis, or the direct care and treatment of the member’s condition, illness, disease or injury; and c) in accordance with standards of good medical practice; and d) not primarily for the convenience of the BSMUHDHP3500-O member, or the member’s physician and/or other provider; and e) the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member’s condition, and the member cannot receive safe or adequate care as an outpatient. Network facility providers, network professional providers and PremierBlue Shield professional providers (out-of-area) will accept this determination of medical necessity. Out-of-network providexx xre not obligated to accept this determination and may bill the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.
Sample 1
Medically Necessary and Appropriate. “Medically Necessary and Appropriate” means services or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; and b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. Benefits under the Agreement for services or supplies will be provided only when the Plan or its designated agent, utilizing the criteria set forth in the paragraph above, determines that such service or supply is medically necessary and appropriate. Network facility providers and preferred professional providers will accept this determination of medical necessity. Out-of-Network providers are not obligated to accept this determination and may xxxx the member for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.
Sample 1
Medically Necessary and Appropriate. The services or supplies described in the Agreement are covered only when they are Medically Necessary and Appropriate. The determination of Medical Necessity and Appropriateness is made by the member’s PCP, the network specialist and/or KHPW, or its designated agent. Any covered services requested by a member which are not Medically Necessary and Appropriate will not be covered. The member’s receipt of a preauthorization from KHPW, or its designated agent, to receive services from a provider outside the network shall constitute proof of Medical Necessity and Appropriateness for purposes of determining a member’s potential liability for covered services. Medically Necessary and Appropriate is defined as follows: Services or supplies provided by a provider that the PCP, network specialist and/or KHPW, or its designated agent, determine are: a. appropriate for the symptoms and diagnosis or treatment of the member's condition, illness, disease or injury; and b. provided for the diagnosis, or the direct care and treatment of the member's condition, illness, disease or injury; and c. in accordance with standards of good medical practice; and d. not primarily for the convenience of the member or the member's provider; and e. the most appropriate supply or level of service that can safely be provided to the member. When applied to hospitalization, this further means that the member requires acute care as an inpatient due to the nature of the services rendered or the member's condition, and the member cannot receive safe or adequate care in some other setting without adversely affecting the member’s condition or quality of medical care. No benefits will be provided hereunder unless it is determined that the service or supply is Medically Necessary and Appropriate.
Sample 1
Medically Necessary and Appropriate. “Medically Necessary and Appropriate” means that the benefits under this Agreement for services received from a participating provider will be provided only when and so long as such services are determined by the Plan or its designated agent to be: 1) appropriate for the symptoms and diagnosis or treatment of the subscriber’s condition, illness, disease or injury; and 2) provided for the diagnosis, of the direct care and treatment of the subscriber’s condition, illness, disease or injury; and 3) in accordance with standards of good medical practice; and 4) not primarily for the convenience of the subscriber, or the subscriber’s physician and/or other provider; and 5) the most appropriate supply or level of service that can safely be provided to the subscriber. When applied to hospitalization, this further means that the subscriber requires acute care as a bed patient due to the nature of the services rendered or the subscriber’s condition, and the subscriber cannot receive safe or adequate care as an outpatient. Participating hospitals, facility other providers and professional providers will accept this determination of medical necessity. Non-participating providers are not obligated to accept this determination and may bill the subscriber for services determined not to be medically necessary and appropriate. See the Agreement for further explanation.
Sample 1

Related to Medically Necessary and Appropriate

  • Medically Necessary In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Contract.

  • Know-How Necessary for the Business The Intellectual Property Rights are all those necessary for the operation of the Company’s businesses as it is currently conducted or as represented, in writing, to the Purchasers to be conducted. The Company is the owner of all right, title, and interest in and to each of the Intellectual Property Rights, free and clear of all liens, security interests, charges, encumbrances, equities, and other adverse claims, and has the right to use all of the Intellectual Property Rights. To the Company’s knowledge, no employee of the Company has entered into any contract that restricts or limits in any way the scope or type of work in which the employee may be engaged or requires the employee to transfer, assign, or disclose information concerning his work to anyone other than of the Company.

  • Agreement to Perform Necessary Acts Each party agrees to perform any further acts and execute and deliver any further documents which may be reasonably necessary or otherwise reasonably required to carry out the provisions of this Agreement.

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  • Reasonable and Necessary Restrictions The Executive acknowledges that the restrictions, prohibitions and other provisions hereof, including, without limitation the Restriction Period, are reasonable, fair and equitable in terms of duration, scope and geographic area, are necessary to protect the legitimate business interests of the Company and are a material inducement to the Company to enter into this Agreement.

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  • Information and Services Required of the Owner The Owner shall provide information with reasonable promptness, regarding requirements for and limitations on the Project, including a written program which shall set forth the Owner’s objectives, constraints, and criteria, including schedule, space requirements and relationships, flexibility and expandability, special equipment, systems, sustainability and site requirements.

  • Necessary Authority The Scheduling Coordinator represents and warrants that all of the entities which it identifies on Schedule 1 as Scheduling Coordinator Metered Entities that it represents have granted it all necessary authority to enable it to carry out its obligations under this Agreement and the CAISO Tariff, and, subject to the execution and delivery by the CAISO, this Agreement will be enforceable against the Scheduling Coordinator in accordance with its terms.

  • Necessary Governmental Approvals The parties shall have received all approvals and actions of or by all Governmental Bodies which are necessary to consummate the transactions contemplated hereby, which are either specified in Schedule 5.3(B)(ii) or otherwise required to be obtained prior to the Closing by applicable Requirements of Laws.

  • Good Faith and Commercially Reasonable Manner Performance of all obligations under this Annex, including, but not limited to, all calculations, valuations and determinations made by either party, will be made in good faith and in a commercially reasonable manner.

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