Outpatient Services Clause Samples
The Outpatient Services clause defines the terms and conditions under which medical services provided to patients who are not admitted to a hospital are covered. It typically outlines which types of outpatient treatments, such as diagnostic tests, minor surgical procedures, or specialist consultations, are included or excluded under the agreement. This clause ensures clarity regarding the scope of coverage for non-hospitalized care, helping both parties understand their rights and obligations and preventing disputes over what outpatient services are reimbursable.
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Outpatient Services. Medical treatments or services provided or ordered by a physician for the Insured when the Insured is not admitted at a Hospital. Outpatient services may include services performed in a hospital or emergency room.
Outpatient Services. Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require Enrolled Members to pay in full at the time of service. Enrolled Members must submit a claim to obtain reimbursement for covered healthcare services. Preauthorization is recommended for outpatient services.
Outpatient Services. The following services are covered only at the Primary Care Provider’s office[selected by a [Member], or elsewhere [upon prior written Referral by a [Member]'s Primary Care Provider ]:
1. Office visits during office hours, and during non-office hours when Medically Necessary and Appropriate.
2. Home visits by a [Member]'s Primary Care Provider.
3. Periodic health examinations to include:
a. Well child care from birth including immunizations;
b. Routine physical examinations, including eye examinations;
c. Routine gynecologic exams and related services;
d. Routine ear and hearing examination; and
e. Routine allergy injections and immunizations (but not if solely for the purpose of travel or as a requirement of a [Member]'s employment).
Outpatient Services. Outpatient services are defined as those preventive, diagnostic, therapeutic, rehabilitative, surgical, mental health, facility services for dental, and Emergency Services received by a patient through an outpatient/ambulatory care facility for the treatment of a disease or injury for a period of time generally not exceeding twenty- four (24) hours. Outpatient or ambulatory care facilities include: (a) Hospital Outpatient Departments, (b) Diagnostic/Treatment Centers, (c) Ambulatory Surgical Centers, (d) Emergency Rooms (ERs), (e) End Stage Renal Disease (ESRD) Clinics and (f) Outpatient Pediatric AIDS Clinics (OPAC). The CONTRACTOR shall:
4.2.19.1. Refer to the Medicaid Managed Care Policy and Procedure Guide and applicable manuals for additional details regarding this Benefit/service coverage requirement.
Outpatient Services. The following services are covered [only] at the Primary Care Physician’s office [or other Network Facility or Practitioner’s office] selected by a [Member][, or elsewhere upon prior written Referral by a [Member]'s Primary Care Physician]:
1. Office visits during office hours, and during non-office hours when Medically Necessary and Appropriate.
2. Home visits by a [Member]'s Primary Care Physician.
3. Preventive Care, including but not limited to Periodic health examinations such as:
a. Well child care from birth including immunizations;
b. Routine physical examinations, including eye examinations;
c. Routine gynecologic exams and related services;
d. Routine ear and hearing examination; and
e. Routine allergy injections and immunizations (but not if solely for the purpose of travel or as a requirement of a [Member]'s employment).
Outpatient Services. The following services are covered [only] at the Primary Care Physician’s office [or Health Center] [or other Network Facility or Practitioner’s office] selected by a [Member][, or elsewhere upon prior written Referral by a [Member]'s Primary Care Physician [or Health Center] [or the Care Manager]]:
1. Office visits during office hours, and during non-office hours when Medically Necessary and Appropriate.
2. Home visits by a [Member]'s Primary Care Physician.
3. Periodic health examinations to include:
a. Well child care from birth including immunizations;
b. Routine physical examinations, including eye examinations;
c. Routine gynecologic exams and related services;
d. Routine ear and hearing examination; and
e. Routine allergy injections and immunizations (but not if solely for the purpose of travel or as a requirement of a [Member]'s employment).
Outpatient Services. ASAM Level 1 – means outpatient drug free (ODF) services are provided to adults and youth experiencing a SUD who meet medical necessity for this level of care, determined by an LPHA or physician’s diagnosis and County-based ASAM criteria. Services shall be less than nine (9) hours per week for adults and less than six (6) hour per week for adolescents.
Outpatient Services. The following services are covered only at the Primary Care Provider’s office[selected by a [Member], or elsewhere [upon prior written Referral by a [Member]'s Primary Care Provider ]:
1. Office visits during office hours, and during non-office hours when Medically Necessary and Appropriate. [Virtual primary care] [and] [walk-in clinic visits], as described below, [is] [are] also available. We cover virtual primary care (VPC) without deductible, copayment or coinsurance for the services listed below for [all] members [18 years of age or older]. VPC is in addition to and does not replace coverage of in-person or Telemedicine or Telehealth visits to a Primary Care Provider. [VPC must be provided by Practitioner, whose network contract with Us is to provide VPC by Telemedicine.] Covered VPC Telemedicine services include:
a) General primary care consultations;
b) Preventive care screening and counseling;
c) Preventive care biometric review and analysis: − If a Member will perform self-assessments, the Member will be provided with a blood pressure cuff and heart monitor at no cost when the first VPC consultation is scheduled. − A Member’s results may be self-reported or reviewed by a VPC Telemedicine Practitioner by a remote device;
d) Consultations for non-emergency Illness or Injury, including prescriptions, when needed
e) Prescription drug coordination to encourage safe and appropriate use of medications
f) Follow-up care and coordination with Practitioners The VPC telemedicine Practitioner can help a Member identify network Practitioners for covered services ordered during a virtual consultation, including:
a) Diagnostic lab tests
b) Preventive care immunizations
c) In-person preventive care
d) In-person biometric screenings such as cholesterol and blood sugar testing The applicable deductible, copayment or coinsurance will apply for services not provided by a VPC Telemedicine Practitioner and for any prescription drugs. Note: Telemedicine consultations received from a Practitioner who is not a VPC Telemedicine Practitioner are not covered under this virtual primary care provision.] [We cover health care services provided through a Walk-in Clinic. Covered services include:
a) Scheduled and unscheduled visits for Illnesses and Injuries that are not visits to treat an Emergency;
b) Preventive care immunizations administered within the scope of the Walk-in Clinic’s license;
c) Telemedicine and/or Telehealth consultations;
d) Individual screening and counseling...
Outpatient Services. Outpatient Services are available for the treatment of an Emergency Medical Condition. Physicians, Urgent Care centers and other Outpatient providers located outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands will typically require the Member to pay in full at the time of service. The Member must submit a claim to obtain reimbursement for Covered Medical Expenses.
Outpatient Services. Care and treatment of Mental Illness if the Member is not an Inpatient Member and the care and treatment is provided by: