PAYMENT OF BENEFITS AND PROVISION OF SERVICES AND SUPPLIES Sample Clauses

PAYMENT OF BENEFITS AND PROVISION OF SERVICES AND SUPPLIES. (a) The Contractor may request enrollees to complete reasonable forms or provide information which the Contractor may reasonably request; provided, however, that the Contractor must not require enrollees to complete any form as a precondition of receiving benefits unless the form has first been approved for use by the Commissioner of OFIR. Notwithstanding Section 2(a), forms requiring specific approval do not include claim forms and other forms necessary to receive payment of individual claims. (b) All benefits must be paid (with appropriate documentation of payment) within a reasonable time after receipt of reasonable proof covering the occurrence, character and extent of the event for which the claim is made, in a manner consistent with the timely claims payment requirement found in MCL 500.2006. The claimant must furnish satisfactory evidence that all services or supplies for which expenses are claimed are covered services or supplies within the Contract. (c) The procedures and time period for filing claims must be as specified in the agreed upon Benefit Contract. However, failure to file a claim within the time required must not, in itself, invalidate or reduce any claim where timely filing was prevented by administrative operations or legal incapacitation, provided the claim was submitted as soon as reasonably possible. (d) The Contractor may request an enrollee to submit to one or more medical examinations to determine whether benefits applied for are for services and supplies necessary for the diagnosis or treatment of an illness or injury or covered condition of the enrollee and may withhold payment of such benefits pending completion of the examinations. The examinations must be made at the expense of the Contractor by a physician selected by the enrollee from a panel of at least three physicians whose names are furnished by the Contractor, and the results of the examinations must be made available to the Contractor and the enrollee. (e) As a condition precedent to the provision of benefits hereunder, the Contractor, to the extent reasonable and necessary and consistent with Federal law, will be entitled to obtain from any person, organization or the State all information and records relating to visits or examination of, or treatment rendered or supplies furnished to, an enrollee as the Contractor requires in the administration of such benefits. The Contractor may obtain from any insurance company or other organization or person any information, w...
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Related to PAYMENT OF BENEFITS AND PROVISION OF SERVICES AND SUPPLIES

  • Coordination of Benefits and Subrogation IPA and HMO shall establish and implement a system for coordination of benefits and subrogation, in accordance with those rules established under the HMO's policies and procedures and applicable federal and state laws. If known to IPA, IPA shall identify and inform HMO of Members for whom coordination of benefits and subrogation opportunities exist. HMO hereby authorizes IPA to seek payment, on a fee-for service basis or otherwise, from any insurance carrier, organization, or government agency which is primarily responsible for the payment or provision of medical services provided by IPA under this Agreement which can be recovered by reason of coordination of benefits, motor vehicle injury, worker's compensation, temporary disability, occupational disease, or similar exclusionary or limiting provisions, to the extent authorized by the applicable and not otherwise prohibited by law.

  • Coordination of Benefits i. Delta Dental coordinates the dental Benefits under this dental plan with your benefits under any other group or pre-paid plan or insurance plan designed to fully integrate with other plans. If this plan is the “primary” plan, Delta Dental will not reduce Benefits. If this plan is the “secondary” plan, Delta Dental may reduce Benefits so that the total benefits paid or provided by all plans do not exceed 100% of total allowable expense. ii. How does Delta Dental determine which Plan is the “primary” plan? 1) The plan covering the Enrollee as an employee is primary over a plan covering the Enrollee as a dependent. 2) The plan covering the Enrollee as an employee is primary over a plan covering the insured person as a dependent; except that if the insured person is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security Act and implementing regulations, Medicare is: a) secondary to the plan covering the insured person as a dependent; and b) primary to the plan covering the insured person as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the insured person as a dependent are determined before those of the plan covering that insured person as other than a dependent. 3) Except as stated in paragraph 4), when this plan and another plan cover the same child as a dependent of different persons, called parents: a) the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year; but b) if both parents have the same birthday, the benefits of the plan covering one parent longer are determined before those of the plan covering the other parent for a shorter period of time. c) However, if the other plan does not have the birthday rule described above, but instead has a rule based on the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan determines the order of benefits. 4) In the case of a dependent child of legally separated or divorced parents, the plan covering the Enrollee as a dependent of the parent with legal custody or as a dependent of the custodial parent’s spouse (i.e. step-parent) will be primary over the plan covering the Enrollee as a dependent of the parent without legal custody. If there is a court decree establishing financial responsibility for the health care expenses with respect to the child, the benefits of a plan covering the child as a dependent of the parent with such financial responsibility will be determined before the benefits of any other policy covering the child as a dependent child. 5) If the specific terms of a court decree state that the parents will share joint custody without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules outlined in paragraph 3). 6) The benefits of a plan covering an insured person as an employee who is neither laid-off nor retired are determined before those of a plan covering that insured person as a laid-off or retired employee. The same would hold true if an insured person is a dependent of a person covered as a retiree or an employee. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule 6) is ignored. 7) If an insured person whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the following will be the order of benefit determination. a) First, the benefits of a plan covering the insured person as an employee (or as that insured person’s dependent). b) Second, the benefits under the continuation coverage. c) If the other plan does not have the rule described above, and if, as a result, the plans do not agree on the order of benefits, this rule 7) is ignored. 8) If none of the above rules determines the order of benefits, the benefits of the plan covering an employee longer are determined before those of the plan covering that insured person for the shorter term. 9) When determination cannot be made in accordance with the above for Pediatric Benefits, the benefits of a plan that is a medical plan covering dental as a benefit will be primary to a dental only plan.

  • Location of Services Subcontractor will provide the Services at the following address(es): _________________________________________________________________________________________________________________________________________________________.

  • Modification of Services Credit Union reserves the right to modify the Service from time to time without making prior notice to Member, provided, however, that Credit Union will give you at least thirty (30) days notice prior to making any modifications to the Service that would materially alter their functionality.

  • Provision of Services (a) The HSP will provide the Services in accordance with, and otherwise comply with: (1) the terms of this Agreement; (2) Applicable Law; and

  • Cessation of Benefits An employee shall cease to be eligible for benefits of this Plan at the earliest of the following dates: (a) at the end of the month in which the employee reaches his/her sixty-fifth (65th) birthday; (b) on the date of commencement of paid absence prior to retirement; (c) on the date of termination of employment with the Employer. Benefits will not be paid when an employee is serving a prison sentence. Cessation of active employment as a regular employee shall be considered termination of employment except when an employee is on authorized leave of absence with or without pay.

  • Duration of Benefits Eligibility for Income Protection benefits will cease upon the earliest of the following dates: 1.09.01 the date the member is no longer disabled from performing the duties of their regular position, or any alternative employment made available to the member by the City. 1.09.02 the date the member's Income Protection benefits have been expended. 1.09.03 the date the member dies.

  • Provision of Services by Third Parties The Administrator shall, to the extent it determines that it would be advisable in connection with or incidental to the activities contemplated hereby, arrange for and coordinate the services of other professionals, experts and consultants to provide any or all of the Services, in which case, the costs and expenses of such third parties for providing such services shall be borne by the Administrator other than as set forth in Section 3; it being understood that the Administrator shall not charge to the Issuer any fees in addition thereto with respect to such outsourced Painting-Level Services that are described in Section 1(a)(i) and Entity-Level Services described in Section 1(a)(ii), but the Administrator shall be entitled to reimbursement for third party costs incurred in connection with Non-Routine Services described in Section 1(a)(iii) as set forth in Section 3(b). Reimbursement for Non-Routine Services shall be reimbursed by the Issuer out of the proceeds from a sale of the Painting. In addition, Masterworks may determine to sell the Painting without engaging a third-party intermediary, in which event, the Administrator would charge the buyer of the Painting a reasonable fee not to exceed the lowest published buyer’s premium charged by Sotheby’s, Christie’s or Pxxxxxxx in effect at such time.

  • Coordination of Services Consultant agrees to work closely with City staff in the performance of Services and shall be available to City’s staff, consultants and other staff at all reasonable times.

  • Termination of Services 6.2. To promote a non-discriminatory work environment based on the principle of equality, employers and the trade union should adopt appropriate measures to ensure that employees with HIV and AIDS are not unfairly discriminated against and are protected from victimisation through positive measures such as: (i) preventing unfair discrimination and stigmatisation of people living with HIV or AIDS through the development of HIV/AIDS policies and programmes for the workplace; (ii) awareness, education and training on the rights of all persons with regard to HIV and AIDS; (iii) mechanisms to promote acceptance and openness around HIV/AIDS in the workplace; (iv) providing support for all employees infected or affected by HIV and AIDS; and (v) grievance procedures and disciplinary measures to deal with HIV-related complaints in the workplace. 7. HIV TESTING, CONFIDENTIALITY AND DISCLOSURE

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