Outpatient Procedure or Covered Service Sample Clauses

Outpatient Procedure or Covered Service. Precertification a. Network Services The Network Provider is responsible for the Precertification of such procedure or Covered Service. The Member will not be financially responsible whenever certification for such procedure or Covered Service is not obtained by the Network Provider. If the procedure or Covered Service is deemed not to be Medically Necessary and Appropriate, the Member will not be financially responsible, except when the Plan provides prior written notice to the Member that charges for the procedure or Covered Service will not be covered. In such case, the Member will be financially responsible for such procedure or Covered Service. b. Out-of-Area and Out-of-Network Services An Out-of-Area or Out-of-Network Provider is not responsible for the Precertification of any procedure or Covered Service. Whenever a Member utilizes an Out-of-Area or Out-of-Network Provider, the Member should contact the Plan prior to the receipt of a procedure or Covered Service to confirm the Medical Necessity and Appropriateness. However, the Plan may also review certain procedures or Covered Services after they are received to determine Medical Necessity and Appropriateness. If the procedure or Covered Service is determined to be Medically Necessary and Appropriate, benefits will be paid in accordance with this Agreement. The Member will be financially responsible for the difference between what is covered by the Agreement and the full amount of the Out-of-Area or Out-of-Network Provider’s charge. If the procedure or Covered Service is determined not to be Medically Necessary and Appropriate, no benefits will be provided. The Member will be financially responsible for the full amount of the Out-of-Area or Out-of-Network Provider’s charge.
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Outpatient Procedure or Covered Service. Precertification
Sample 1

Related to Outpatient Procedure or Covered Service

  • Dependent Care Assistance Program The County offers the option of enrolling in a Dependent Care Assistance Program (DCAP) designed to qualify for tax savings under Section 129 of the Internal Revenue Code, but such savings are not guaranteed. The program allows employees to set aside up to five thousand dollars ($5,000) of annual salary (before taxes) per calendar year to pay for eligible dependent care (child and elder care) expenses. Any unused balance is forfeited and cannot be recovered by the employee.

  • Covered Services You will receive Covered Services under the terms and conditions of this Contract only when the Covered Service is: • Medically Necessary; • Provided by a Participating Provider for in-network coverage; • Listed as a Covered Service; • Not in excess of any benefit limitations described in the Schedule of Benefits section of this Contract; and • Received while Your Contract is in force.

  • Inpatient If you are an inpatient in a general or specialty hospital for mental health services, this agreement covers medically necessary hospital services and the services of an attending physician for the number of hospital days shown in the Summary of Medical Benefits. See Section

  • Outpatient If you receive infusion therapy services in a hospital's outpatient unit, we cover the use of the treatment room, related supplies, and solutions. For prescription drug coverage, see Section 3.27

  • Volunteer Peer Assistants 1. Up to eight (8)

  • Required Services Consultant agrees to perform the services, and deliver to City the “Deliverables” (if any) described in the attached Exhibit A, incorporated into the Agreement by this reference, within the time frames set forth therein, time being of the essence for this Agreement. The services and/or Deliverables described in Exhibit A shall be referred to herein as the “Required Services.”

  • Non-Medical, Personalized Services The Practice shall also provide Members with the following non-medical services:

  • Disenrollment An Enrollee must be disenrolled from the Plan if the Beneficiary: a. No longer resides in the State of Mississippi; b. Is deceased; c. No longer qualifies for medical assistance under one of the Medicaid eligibility categories in the targeted population. The Contractor must notify the Division within three (3) days of their request that an Enrollee is disenrolled for a reason listed above and provide written documentation of disenrollment. Disenrollment shall be effective on the first day of the calendar month for which the disenrollment appears on the Enrollee Listing Report. The Contractor shall not disenroll an Enrollee because of an adverse change in the Enrollee’s health status, or because of the Enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from Enrollee’s special needs (except when Enrollee’s continued enrollment in the CCO seriously impairs the Contractor’s ability to furnish services to either this particular Enrollee or other Enrollees.) The Contractor must file a request to disenroll an Enrollee with the Division in writing stating specifically the reasons for the request if the reasons are for other than those specified above. An Enrollee may request disenrollment without cause during the ninety (90) days following the date the Division sends the Enrollee notice of enrollment or the date of the Enrollee’s initial enrollment, whichever is later, during the annual open enrollment period, upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the Enrollee to miss the annual disenrollment opportunity, or when the Division imposes an intermediate sanction on the Contractor as specified in this Contract. An Enrollee may request disenrollment from the CCO for cause if the CCO does not, because of moral or religious objections, cover the service the Enrollee seeks, the Enrollee needs related services to be performed at the same time, not all related services are available within the network, the Enrollee’s primary care provider or another provider determines receiving the services separately would subject Enrollee to unnecessary risk, poor quality of care, lack of access to services covered under the Plan, or lack of access to providers experienced in dealing with the Enrollee’s health care needs. Enrollee requests for disenrollment must be directed to the Division either orally or in writing. The effective date of any approved disenrollment will be no later than the first day of the second month following the month in which the Enrollee or the Plan files the request with the Division.

  • DEVELOPMENT OR ASSISTANCE IN DEVELOPMENT OF SPECIFICATIONS REQUIREMENTS/ STATEMENTS OF WORK

  • Non-Covered Services MCOs are not permitted to provide Medicaid excluded services that include, but are not limited to, the following: 1. All non-medically necessary services; 2. Sterilization of a mentally incompetent or institutionalized individual; 3. Except in an emergency, inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practices, who is responsible for the diagnosis or treatment of a particular patient’s condition; 4. All organ transplants, except for those specified in Appendix A; 5. Treatments for infertility5 and for the reversal of sterilization;

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