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

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 AHCA Contract No. FA904, Attachment II, Page 70 of 186 WellCare of Florida, Inc. d/b/a Staywell Health Plan of Florida Medicaid HMO Non-Reform 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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Out-of-Plan Use of Non-Emergency Services a. Unless otherwise specified in this Contract, where an Enrollee utilizes services available under the Health Plan other than Emergency Services from a non-participating provider, the Health Plan shall not be liable for the cost of such utilization unless the Health Plan referred the Enrollee to the non-participating provider or authorized such out-of-network utilization. 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 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. The Enrollee shall be liable for the cost of such unauthorized use of Covered Services from non-participating providers.
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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:
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Related to Out-of-Plan Use of Non-Emergency Services

  • Emergency Services HMO policy and procedures, Covered Services, claims adjudication methodology, and reimbursement performance for Emergency Services must comply with all applicable state and federal laws, rules, and regulations including 42 C.F.R. §438.114, whether the provider is in-network or Out-of-Network. HMO policies and procedures must be consistent with the prudent layperson definition of an Emergency Medical Condition and the claims adjudication processes required under the Contract and 42 C.F.R. §438.114. The HMO must pay for the professional, facility, and ancillary services that are Medically Necessary to perform the medical screening examination and stabilization of a Member presenting with an Emergency Medical Condition or an Emergency Behavioral Health Condition to the hospital emergency department, 24 hours a day, 7 days a week, rendered by either the HMO's Network or Out-of-Network providers. The HMO cannot require prior authorization as a condition for payment for an Emergency Medical Condition, an Emergency Behavioral Health Condition, or labor and delivery. The HMO cannot limit what constitutes an Emergency Medical Condition on the basis of lists of diagnoses or symptoms. The HMO cannot refuse to cover Emergency Services based on the emergency room provider, hospital, or fiscal agent not notifying the Member’s PCP or the HMO of the Member’s screening and treatment within 10 calendar days of presentation for Emergency Services. The HMO may not hold the Member who has an Emergency Medical Condition liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient. The HMO must accept the emergency physician or provider’s determination of when the Member is sufficiently stabilized for transfer or discharge.

  • Use of Immobilization Programs Provided (i) the Bank has received a certified copy of a resolution of the Board specifically approving the maintenance of Portfolio Securities in an immobilization program operated by a bank which meets the requirements of Section 26(a)(1) of the 1940 Act, and (ii) for each year following such approval the Board has reviewed and approved the arrangement and has not delivered an Officer's Certificate to the Bank indicating that the Board has withdrawn its approval, the Bank shall enter into such immobilization program with such bank acting as a subcustodian hereunder.

  • Omnibus Transparency Services Upon request of the Fund, the Transfer Agent shall carry out certain information requests, analyses and reporting services in support of the Fund’s obligations under Rule 22c-2(a)(2). The parties will agree to such services and terms as stated in the attached schedule (“Schedule 1.1(y)” entitled “Omnibus Transparency Services”) that may be changed from time to time subject to mutual written agreement between the parties.

  • DATA ACCESS SERVICES ADDENDUM TO CUSTODIAN AGREEMENT Addendum to the Custodian Agreement (as defined below) between each fund listed on Appendix A to the Custodian Agreement, as such Appendix A is amended from time to time (each such fund listed on Appendix A shall be individually referred to herein as the “Fund”), and State Street Bank and Trust Company (“State Street”).

  • REMOTE ACCESS SERVICES ADDENDUM The Custodian and each Fund agree to be bound by the terms of the Remote Access Services Addendum hereto.

  • Security Against Unauthorized Use of Funds’ Recordkeeping Systems Financial Intermediary agrees to provide such security as is necessary to prevent any unauthorized use of the Funds’ recordkeeping system, accessed via (a) the world wide web or any URL maintained by the Funds or JPMDS, (b) a networking/data access arrangement or (c) computer hardware or software provided to Financial Intermediary by JPMDS.

  • Limitation on Services None of the services rendered or to be rendered by the Consultant and paid for by the issuance of shares of the Company's common stock or the Option shall be services related to any "capital raising" transaction.

  • Description of Consulting Services Consultant shall perform the following services pursuant to the terms of this Agreement:

  • IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an Account. When the Company opens an Account the Bank will ask for the depositor's name, address and other information that will allow the Bank to identify the depositor. The Bank may also ask to see other documents that substantiate the depositor's identity.

  • Services and Duties of Fund Services Fund Services shall provide the following administration services to each Fund:

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