Monitoring of Potentially Low-Value Services Sample Clauses

Monitoring of Potentially Low-Value Services. The CONTRACTOR must provide reporting on select services identified by the DEPARTMENT as potentially low value to PARTICIPANTS. The DEPARTMENT will develop the list of services to be studied on an annual basis. The CONTRACTOR will provide analysis of the utilization of services and potential impact of alternate care pathways. 220 Benefits‌ 220A Overview‌ The CONTRACTOR must provide the BENEFITS and services listed in UNIFORM BENEFITS to all PARTICIPANTS. BENEFITS are reviewed annually and any BENEFIT changes must be implemented as directed by the BOARD. This shall include developing the necessary reporting and/or data transfers needed by the DEPARTMENT and other vendors to administer the change. The CONTRACTOR will offer the HDHP described in UNIFORM BENEFITS to all enrolled PARTICIPANTS. This paragraph does not apply to the MEDICARE ADVANTAGE CONTRACTOR. 220B Telehealth / Nurse Line‌ The CONTRACTOR must provide access to immediate care services such as telehealth and/or a twenty-four (24) hour nurse line to PARTICIPANTS. Such services must provide at minimum consultation services that assist PARTICIPANTS in determining whether additional treatment for a condition should be sought. Such consultation services that result in a referral to a different site of care rather than definitive treatment should be provided at no cost to PARTICIPANTS. 220C Emergency / Urgent / Catastrophic Care‌ The CONTRACTOR must cover emergency and urgent care and related catastrophic medical care received from IN-NETWORK or OUT-OF-NETWORK providers at the IN-NETWORK level of benefits. This OUT-OF-NETWORK care may be subject to usual and customary charges while holding the PARTICIPANT harmless as described in UNIFORM BENEFITS unless the PARTICIPANT accepted financial responsibility, in writing, for the specific treatment or services (i.e., diagnosis and/or procedure code(s) and related charges) prior to receiving services. The CONTRACTOR must make every effort to settle claim disputes in a reasonable time frame. The CONTRACTOR will work with OUT-OF-NETWORK providers to manage and reduce medical claim costs incurred in emergency and urgent situations. The CONTRACTOR must coordinate care in these situations, including directing care IN-NETWORK, authorizing follow-up care on a case-by-case basis, and/or a transfer to a more suitable facility when appropriate. The CONTRACTOR will provide coverage for certain mental health services OUT-OF-NETWORK as required by law for college students ...

Monitoring of Potentially Low-Value Services. The CONTRACTOR must provide reporting on select services identified by the DEPARTMENT as potentially low value to PARTICIPANTS. The DEPARTMENT will develop the list of services to be studied on an annual basis. The CONTRACTOR will provide analysis of the utilization of services and potential impact of alternate care pathways.