Out-of-Plan Use of Non-Emergency Services Sample Clauses

Out-of-Plan Use of Non-Emergency Services. Unless otherwise specified in this Contract, where an Enrollee utilizes services available under the Health Plan other than emergency services from a non-contract provider, the Health Plan shall not be liable for the cost of such utilization unless the Health Plan referred the Enrollee to the non-contract provider or authorized such out-of-plan utilization. The Health Plan shall provide timely approval or denial of authorization of out-of-plan use through the assignment of a prior authorization number, which refers to and documents the approval. A Health Plan may not require paper authorization as a condition of receiving treatment if the plan has an automated authorization system. Written follow up documentation of the approval must be provided to the out-of-plan provider within one (1) Business Day from the request for approval. The Enrollee shall be liable for the cost of such unauthorized use of contract-covered services from non-contract providers. In accordance with section 409.912, F.S., the Health Plan shall reimburse any hospital or physician that is outside the Health Plan’s authorized geographic service area for Health Plan authorized services provided by the hospital or physician to plan members at a rate negotiated with the hospital or physician for the provision of services or according to the lesser of the following: a. The usual and customary charge made to the general public by the hospital or physician; or b. The Florida Medicaid reimbursement rate established for the hospital or physician. The plan shall reimburse all out-of-plan providers pursuant to section 641.3155, F.S.
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Out-of-Plan Use of Non-Emergency Services. The Health Plan shall provide timely approval or denial of authorization of out-of-network use through the assignment of a prior authorization number, which refers to and documents the approval. The Health Plan may not require paper authorization as a condition of receiving treatment if the Health Plan has an automated authorization AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract system. Written follow-up documentation of the approval must be provided to the out-of-network provider within one (1) business day from the request for approval. For capitated Health Plan enrollees, the enrollee shall be liable for the cost of such unauthorized use of covered services from non-participating providers.
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Related to Out-of-Plan Use of Non-Emergency Services

  • Emergency Services The parties recognize that in the event of a strike or lockout, situations may arise of an emergency nature. To this end, the Employer and the Union will agree to provide services of an emergency nature.

  • Emergency Service Leave Where employees' services are required for emergency operations by request from Provincial Emergency Programs or appropriate police authority, leave from work as required may be granted without loss of basic pay. If any remuneration, other than for expenses, is received, it shall be remitted to the Employer.

  • Developer Compensation for Emergency Services If, during an Emergency State, the Developer provides services at the request or direction of the NYISO or Connecting Transmission Owner, the Developer will be compensated for such services in accordance with the NYISO Services Tariff.

  • Emergency Services Leave (a) An Employee who engages in a voluntary emergency management activity is entitled to be absent without loss of pay from his or her employment for a total of 5 days per annum commencing at the start of each calendar year. For the avoidance of doubt, any days not utilised by the Employee by the end of the calendar year, do not carry over into the subsequent year. (b) Voluntary emergency management activity has the meaning provided by the FWA.

  • Emergency Room Services This plan covers services received in a hospital emergency room when needed to stabilize or initiate treatment in an emergency. If your condition needs immediate or urgent, but non-emergency care, contact your PCP or use an urgent care center. This plan covers bandages, crutches, canes, collars, and other supplies incidental to your treatment in the emergency room as part of our allowance for the emergency room services. Additional services provided in the emergency room such as radiology or physician consultations are covered separately from emergency room services and may require additional copayments. The amount you pay is based on the type of service being rendered. Follow-up care services, such as suture removal, fracture care or wound care, received at the emergency room will require an additional emergency room copayment. Follow- up care services can be obtained from your primary care provider or a specialist. See Dental Services in Section 3 for information regarding emergency dental care services.

  • EMERGENCY SERVICE If you are unable to reach Administrator at 877.634.0964 and you require emergency repair, you may contact any manufacturer authorized service repair facility listed in Your phone book or online. Mail Administrator Your original repair bill along with the technician’s report and a copy of the Agreement to the address at the top of this Agreement for reimbursement. All coverage and exclusions in this Agreement will apply.

  • CHANGES IN EMERGENCY AND SERVICE CONTACT PERSONS In the event that the name or telephone number of any emergency or service contact for the Competitive Supplier changes, Competitive Supplier shall give prompt notice to the Town in the manner set forth in Article 18.3. In the event that the name or telephone number of any such contact person for the Town changes, prompt notice shall be given to the Competitive Supplier in the manner set forth in Article 18.3.

  • General Description of Services The A-E will be contacted by County Project Management staff on an “as-needed” basis as projects arise to provide A-E for professional services. Requirements will be discussed by both Parties and A-E shall prepare a written Scope Statement that will include the specific work to be performed, including the costs and time required to complete the project/task. Orange County Project Management staff will then review the A-E’s Scope Statement, proceed with negotiation of task costs and when satisfied, issue a Contract Task Order (“CTO”) against this Contract. The A-E shall serve as lead of a design team that may include other construction design professionals working together to ensure that the original design is carried through to the finished product, with no alterations in materials or design that would lead to safety issues or compromise the quality of the building or building component. Other team members who may be retained by the lead to support a project as a consultant may include but are not limited to landscape architects, lighting designers, data consultants, security consultants, controls engineers, commissioning consultants, traffic engineers, surveyors, estimators, special inspection, etc. The A-E shall be responsible for the preparation of comprehensive building assessments, designs, drawings, specifications, cost estimates, and reports within the scope of the CTO. In the preparation of construction drawings and specification, the A-E shall also responsible for: A. Obtaining data by reviewing record drawings, visiting the site of the construction and by conferences with the User/Client and facility maintenance staff or by other actions as necessary to develop the design; B. Checking of shop drawings, submittals, materials and other data submitted by the Construction Contractor for approval; C. Furnishing consultation and advice to County to clarify the intent of the drawings and specifications and on questions that may arise during the construction of the project; D. Space planning, programming and code compliance review and upgrades; E. The meeting of submittal dates included in the Scope Statement of the Contract Task Order, including the work of consultants; F. Coordination with various agencies having authority of jurisdiction for planning services, entitlement, fire life safety, CEQA, ADA, etc.; G. Construction administration services, testing and commissioning; H. Close out services, as-built plans, material lists, project acceptance, etc. I. The coordination of the various elements of the design to assure compatibility of architectural, structural, electrical, mechanical/plumbing, and other design features; J. Other services as specifically included in the Contract Task Order related to project Initiation, Planning/Design, Bid/Award, Construction and Closeout. The A-E shall restrict themselves to the Scope Statement of the Contract Task Order. Any changes in the Scope Statement shall require prior written authorization by County.

  • Provisions of Plan Control This Agreement is subject to all the terms, conditions and provisions of the Plan, including the amendment provisions thereof, and to such rules, regulations and interpretations relating to the Plan as may be adopted by the Committee and as may be in effect from time to time. The Plan is incorporated herein by reference. If and to the extent that this Agreement conflicts or is inconsistent with the Plan, the Plan shall control, and this Agreement shall be deemed to be modified accordingly.

  • Emergency Mode Operation Plan Contractor must establish a documented plan to enable continuation of critical business processes and protection of the security of electronic County PHI or PI in the event of an emergency. Emergency means any circumstance or situation that causes normal computer operations to become unavailable for use in performing the work required under this Agreement for more than twenty-four (24) hours.

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