Professional Provider Services Sample Clauses
The 'Professional Provider Services' clause defines the scope and standards of services to be delivered by a professional service provider under the agreement. It typically outlines the types of services to be performed, the qualifications or credentials required of the provider, and any applicable performance standards or timelines. For example, it may specify that consulting, technical support, or specialized expertise will be provided according to industry best practices. This clause ensures that both parties have a clear understanding of the expectations and requirements for the services, thereby reducing the risk of disputes over service quality or deliverables.
Professional Provider Services a. Except as limited, the following are covered:
(1) Surgery and anesthesia services to include coverage for the administration of general anesthesia for dental care provided to the following covered persons:
(a) A child five (5) years of age and under
(b) A person who is severely disabled
(c) A person who has a medical or behavioral condition that requires hospitalization or general anesthesia when dental care is provided
(2) Treatment of fractures and dislocations.
(3) Biopsies and aspirations.
(4) Endoscopic (scope) procedures.
(5) Maternity services (including the obstetrical and delivery expenses of the birth mother of a child adopted within 90 days of birth of such child).
(6) Medical (non-surgical) services for Inpatients in a Hospital or Medical Care Facility. (See 4.b for details of this benefit.)
(7) Diagnostic radiology services and Imaging studies.
(8) Diagnostic laboratory services.
(9) Radiation therapy.
(10) Chemotherapy, other than High-Dose Chemotherapy, for malignant conditions. (See 4.c for details of the standard chemotherapy benefit and the Special Situations section for High-Dose Chemotherapy with Hematopoietic Support benefits.)
(11) Diagnostic radio isotope studies.
(12) Electroencephalograms (EEGs) and electrocardiograms (EKGs).
Professional Provider Services. Standards of care for eye examinations are entirely consistent with those established by State Departments of Health and include preventive eye care with glaucoma testing, refractive care and the prescribing of eyeglasses. Each patient receives a comprehensive eye examination with a preferred optometrist or ophthalmologist which includes the following components: Case History – chief complaint, eye and vision history, medical history Entrance distance acuities External ocular evaluation including slit lamp examination Internal ocular examination inclusive of dilated fundus evaluation Tonometry Distance refraction – objective and subjective Binocular coordination and ocular motility evaluation Evaluation of pupillary function Biomicroscopy Gross visual fields Assessment and plan Patient education Form completion – school, motor vehicle, etc. All of these components are fully within the education, training and scope of licensure for both optometrists and ophthalmologists. Annual Deductible None None Eye Exam (Once every 12 months) You pay the network provider a $25 copay No claim filing is required. You pay the expense in full and file a claim with EyeMed. The Plan reimburses you up to $42. Lenses* (Once every 12 months)* Standard Progressive Lens Premium Progressive Lens You pay the network provider $0 co-pay for just lenses. $65 co-pay 20% off retail price, then apply a $55 allowance, and you pay the remaining amount. You pay the expense in full and file a claim with EyeMed. The Plan reimburses you after copay as follows: Single vision – up to $40 Bifocal – up to $60 Trifocal – up to $80 Lenticular – up to $125 Plan reimburses up to $60 Plan reimburses up to $60 Frames* (Once every 12 months)* $0 copay, $115 allowance, then 20% off balance over $115, and you pay the remaining amount. Reimbursement up to $45. You pay the expense in full and file a claim with EyeMed. Contact Lenses (Once every 12 months – allowances cover material only)* Conventional: Disposable: Medically Necessary: $0 Co-pay, $105 allowance, then 15% off balance over $105 and you pay the remaining amount $0 Co-pay, $105 allowance $0 Co-pay, plan pays in full You pay the expense in full and file a claim with EyeMed. The plan reimburses you up to $105 after co-pay The plan reimburses you up to $105 after co-pay The plan reimburses you up to $210 Laser Vision Correction Discounts available. No discounts available. * Limited to one pair of prescription eyeglasses or one pair of prescription co...
Professional Provider Services. Standards of care for eye examinations are entirely consistent with those established by State Departments of Health and include preventive eye care with glaucoma testing, refractive care and the prescribing of eyeglasses.