CLAIM FILING AND PROVIDER PAYMENTS This section provides information regarding how a member may file a claim for a covered healthcare service and how we pay providers for a covered healthcare service. How to File a Claim Network providers file claims on your behalf. Non-network providers may or may not file claims on your behalf. If a non-network provider does not file a claim on your behalf, you will need to file it yourself. To file a claim, please send us the provider’s itemized bill, and include the following information: • your name; • your member ID number; • the name, address, and telephone number of the provider who performed the service; • date and description of the service; and • charge for that service. Please send your claim to the address listed in the Contact Information section. Claims must be filed within one calendar year of the date you receive a covered healthcare service. Claims submitted after this deadline are not eligible for reimbursement. This timeframe does not apply if you are legally incapacitated. How Network Providers Are Paid We pay network providers directly for covered healthcare services. Network providers agree not to bill, charge, collect a deposit from, or seek reimbursement from you for a covered healthcare service, except for your share under the plan. When you see a network provider, you are responsible for a share of the cost of covered healthcare services. Your share includes the deductible, if one applies, and the copayment, as listed in the Summary of Medical Benefits. The covered healthcare service may also have a benefit limit, which caps the amount we will reimburse the provider for that service. You will be responsible for any amount over the benefit limit, up to the allowance. Your provider may request these payments at the time of service, or may bill you after the service. If you do not pay your provider, the provider may decline to provide current or future services or may pursue payment from you, such as beginning collection proceedings. Some of our agreements with network providers include alternative payment methods such as incentives, risk-sharing, care coordination, value-based, capitation or similar payment methods. Your copayments are determined based on our allowance at the date the service is rendered. Your copayment may be more or less than the amount the network provider receives under these alternative payment methods. Your copayment will not be adjusted based on these alternative payment methods, or for any payment that is not calculated on an individual claim basis. Our contracts with providers may establish a payment allowance for multiple covered healthcare services, and we may apply a single copayment based on these arrangements. In these cases, you will typically be responsible for fewer copayments than if your share of the cost had been determined on a per service basis.
Annexes and Protocols The Annexes and the Protocols to this Agreement are an integral part of it. The Joint Committee may decide to amend the Annexes and Protocols.
FULLY BARGAINED PROVISIONS A. This Agreement represents and incorporates the complete and final understanding and settlement by the parties of all bargainable issues which were or could have been the subject of negotiations. During the term of this Agreement, neither party will be required to negotiate with respect to any such matter whether or not covered by this Agreement, and whether or not within the knowledge or contemplation of either or both of the parties at the time they negotiated or signed this Agreement.
FACTS AND PROVISIONS/LEGAL REQUIREMENTS The term of the Agreement shall be from September 1, 2015, through May 31, 2018. The County may terminate its participation in the Agreement by providing 90 days advance written notice to the other participating agencies. The Department will provide its personnel assigned to OPSG Grant Program with all supplies and/or prescribed safety gear, body armor, and/or standard issue equipment necessary to perform OPSG Grant Program activities. The County agrees to defend and indemnify the County of San Diego for any claim, action, or proceeding against the County of San Diego arising solely out of the acts or omissions of the County in the performance of the Agreement. Each party to the Agreement agrees to defend itself from any claim, action, or proceeding arising out of concurrent acts or omissions of the parties. In such a case, each party agrees to retain its own legal counsel, bear its own defense costs, and waive its right to seek reimbursement of such costs except where a court finds and allocates comparative fault. Board approval is required for this Agreement, as the funding amount exceeds the authority previously delegated by the Board to the Sheriff on May 15, 2015. County Counsel has approved the attached Agreement as to form. The Honorable Board of Supervisors 5/17/2016
Permitted Uses and Disclosures of Phi by Business Associate Except as otherwise indicated in this Agreement, Business Associate may use or disclose PHI, inclusive of de-identified data derived from such PHI, only to perform functions, activities or services specified in this Agreement on behalf of DHCS, provided that such use or disclosure would not violate HIPAA or other applicable laws if done by DHCS.
Permitted Uses and Disclosure by Business Associate (1) General Use and Disclosure Provisions Except as otherwise limited in this Section of the Contract, Business Associate may use or disclose PHI to perform functions, activities, or services for, or on behalf of, Covered Entity as specified in this Contract, provided that such use or disclosure would not violate the HIPAA Standards if done by Covered Entity or the minimum necessary policies and procedures of the Covered Entity.
Excluded Providers 6.4.1 Definition of Excluded Providers In accordance with 42 CFR 438.214(d), the Contractor may not employ or contract with Providers who are Excluded from participation in Federal Health Care Programs under either Section 1128 or 1128(A) of the Social Security Act.
Ordering and Provisioning 53.1 National Exchange Access Center (NEAC)
Rights of Survivorship Unless otherwise stated on the Account Card or documented through the Credit Union’s online application and authentication process, a joint account includes rights of survivorship. This means that when one (1) owner dies, all sums in the account will pass to the surviving owner(s). For a joint account without rights of survivorship, the deceased owner’s interest passes to his or her estate. A surviving owner’s interest is subject to the Credit Union’s statutory lien for the deceased owner’s obligations and to any security interest or pledge granted by a deceased owner, even if a surviving owner did not consent to it.
NO RIGHT OF SURVIVORSHIP NON-TRANSFERABILITY You acknowledge, understand and agree that your account is non-transferable and any rights to your ID and/or contents within your account shall terminate upon your death. Upon receipt of a copy of a death certificate, your account may be terminated and all contents therein permanently deleted.
