Medical Necessity We Cover benefits described in this Contract as long as the dental service, procedure, treatment, test, device, or supply (collectively, “service”) is Medically Necessary e.g. orthodontia. The fact that a Provider has furnished, prescribed, ordered, recommended, or approved the service does not make it Medically Necessary or mean that We have to Cover it. We may base Our decision on a review of: • Your dental records; • Our dental policies and clinical guidelines; • Dental opinions of a professional society, peer review committee or other groups of Physicians; • Reports in peer-reviewed dental literature; • Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; • Professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; • The opinion of health care professionals in the generally-recognized health specialty involved; • The opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: • They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; • They are required for the direct care and treatment or management of that condition; • Your condition would be adversely affected if the services were not provided; • They are provided in accordance with generally-accepted standards of dental practice; • They are not primarily for the convenience of You, Your family, or Your Provider; • They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results; • When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. See the Utilization Review and External Appeal sections of this Contract for Your right to an internal Appeal and external appeal of Our determination that a service is not Medically Necessary.
Extra Trips All trips other than regular runs or supplemental runs shall be awarded to drivers according to the following procedures:
9.7.1 All extra trips shall be assigned in compliance with the following section of this Agreement; provided, however, that no driver shall be eligible to work more than forty (40) hours in any workweek, exclusive of hours worked on Saturday or Sunday, when another eligible driver is available and would not be put into overtime.
9.7.2 Assignment of extra trips shall be made on the basis of a “Trip Board.” The most senior driver who signs up for the extra trip shall be awarded the trip. No driver may give up any extra trip or supplemental run or regular run previously awarded in order to take an extra trip, if Section 9.7.1 above would be violated. There shall be no pre-empting of regular runs by drivers who wish to take extra trips.
9.7.3 Trips are to be dated as they are received by the Transportation Office. All extra trips shall be awarded to the most senior appropriate driver signing the “Trip Board.” If the extra trip is posted before a driver’s regular run clock-out time, the driver has until the driver’s next regular run clock-in time to reply. If there is no reply, the dispatcher shall assign the extra trip to the next senior driver on the sign-up sheet.
9.7.4 Drivers shall not be eligible for extra trips during periods of absence due to illness. Drivers absent for personal illness on the last working day before a Saturday, Sunday, or holiday trip shall not be eligible to drive such trip and will lose his/her turn on the list until the process begins anew. Drivers absent for other reasons will be able to drive such trips provided they contact the Transportation Office by 3:30 p.m. on the last working day prior to the scheduled trip to verify their availability and confirm the start time of the trip.
9.7.5 The dispatch book shall be made available for driver viewing by the Transportation Office.
