Prenatal Care First & Second Trimester Sample Clauses

Prenatal Care First & Second Trimester. For Members entering the CONTRACTOR’s Health Plan in the first or second trimester of pregnancy who are receiving medically necessary covered prenatal care services the day before Enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary prenatal care services without any form of prior approval and without regard to whether such services are being provided by a contracted or out- of-network Provider until such time as the CONTRACTOR can reasonably transfer the Member to a contract Provider without impeding service delivery that, if not provided, might be harmful to the Member’s health.
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Prenatal Care First & Second Trimester. For Members entering the CONTRACTOR’s Health Plan in the first or second trimester of pregnancy who are receiving medically necessary covered prenatal care services the day before Enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary prenatal care services without any form of prior approval and without regard to whether such services are being provided by a contracted or out-of-network Provider until such time as the CONTRACTOR can reasonably transfer the Member to a contract Provider without impeding service delivery that, if not provided, might be harmful to the Member’s health. Prenatal Care Third Trimester; For Members entering the CONTRACTOR’s Health Plan in the third trimester of pregnancy who is receiving medically necessary covered prenatal care services the day before Enrollment, the CONTRACTOR shall be responsible for the costs of continuation of such medically necessary prenatal care services without any form of prior approval and without regard to whether such services are being provided by a contracted or out-of-network Provider. Members Enrolled Upon Termination of Provider Contract In accordance with 42 CFR 430.10(f)(5), the CONTRACTOR must make a good faith effort to give written notice of termination of a contracted Provider, within fifteen (15) Days after receipt or issuance of the termination notice, to each Enrollee who received his or her primary care from, or was seen on a regular basis by, the terminated provider. Members with Appeals in Process The CONTRACTOR shall ensure the continuation of the Member’s Benefits/services while an Appeal is in process if all of the conditions in Section 9 are satisfied and consistent with Federal Regulations [42 CFR 438.420(a); 42 CFR 438.420(b)]. NETWORKS General Medicaid Managed Care Program Network Requirements In accordance with 42 CFR § 438.206, the CONTRACTOR must ensure that it possesses a network of Providers sufficient to provide adequate access to all services covered under this contract. In the development and maintenance of its Provider network, at a minimum, the CONTRACTOR must meet the requirements outlined throughout this Section of this contract and all applicable manuals. The CONTRACTOR shall meet the following requirements: Consider anticipated Medicaid Enrollment. Consider expected utilization of services, taking into consideration the characteristics and health care needs of the specific Medicaid populations represented in a Dep...
Sample 1

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