Outpatient Procedure or Covered Service Precertification Sample Clauses

Outpatient Procedure or Covered Service Precertification. Precertification may be required to determine the Medical Necessity and Appropriateness of certain Outpatient procedures or Covered Services as determined by the Plan. a. In-Area 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 Services An Out-of-Area Provider is not responsible for the Precertification of any procedure or Covered Service. Whenever a Member utilizes an Out-of-Area Provider, the Member is required to 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 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 Provider’s charge.
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Related to Outpatient Procedure or Covered Service Precertification

  • 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

  • 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.

  • Contractor Responsibility for System Agency’s Termination Costs If the System Agency terminates the Contract for cause, the Contractor shall be responsible to the System Agency for all costs incurred by the System Agency and the State of Texas to replace the Contractor. These costs include, but are not limited to, the costs of procuring a substitute vendor and the cost of any claim or litigation attributable to Contractor’s failure to perform any Work in accordance with the terms of the Contract.

  • Medical Verification The Town may require medical verification of an employee’s absence if the Town perceives the employee is abusing sick leave or has used an excessive amount of sick leave. The Town may require medical verification of an employee’s absence to verify that the employee is able to return to work with or without restrictions.

  • PRIME CONTRACTOR RESPONSIBILITY The contractor will be required to assume prime contractor responsibility for the contract and will be the sole point of contact with regard to all commodities, services and support. The prime contractor may delegate facilitation of contract orders to their “Authorized/Certified Dealers” only. This delegation will in no way relieve the contractor of any contractual obligations set forth in this Contract Award.

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

  • Contractor Certification for Contractor Employees Introduction Texas Education Code Chapter 22 requires entities that contract with school districts to provide services to obtain criminal history record information regarding covered employees. Contractors must certify to the district that they have complied. Covered employees with disqualifying criminal histories are prohibited from serving at a school district. Definitions: Covered employees: Employees of a contractor or subcontractor who have or will have continuing duties related to the service to be performed at the District and have or will have direct contact with students. The District will be the final arbiter of what constitutes direct contact with students. Disqualifying criminal history: Any conviction or other criminal history information designated by the District, or one of the following offenses, if at the time of the offense, the victim was under 18 or enrolled in a public school: (a) a felony offense under Title 5, Texas Penal Code; (b) an offense for which a defendant is required to register as a sex offender under Chapter 62, Texas Code of Criminal Procedure; or (c) an equivalent offense under federal law or the laws of another state. I certify that: NONE (Section A) of the employees of Contractor and any subcontractors are covered employees, as defined above. If this box is checked, I further certify that Contractor has taken precautions or imposed conditions to ensure that the employees of Contractor and any subcontractor will not become covered employees. Contractor will maintain these precautions or conditions throughout the time the contracted services are provided. OR SOME (Section B) or all of the employees of Contractor and any subcontractor are covered employees. If this box is checked, I further certify that: (1) Contractor has obtained all required criminal history record information regarding its covered employees. None of the covered employees has a disqualifying criminal history.

  • Contractor Responsibility (a) The Contractor shall be responsible for the entire Performance under the Contract regardless of whether the Contractor itself performs. The Contractor shall be the sole point of contact concerning the management of the Contract, including Performance and payment issues. The Contractor is solely and completely responsible for adherence by the Contractor Parties to all applicable provisions of the Contract. (b) The Contractor shall exercise all reasonable care to avoid damage to the State's property or to property being made ready for the State's use, and to all property adjacent to any work site. The Contractor shall promptly report any damage, regardless of cause, to the State.

  • In-Service Education The parties recognize the value of in-service both to the employee and the Employer and shall encourage employees to participate in in-service. All employees scheduled by the Employer to attend in-service seminars shall receive regular wages.

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