Recommended Preventive Care Services Clause Samples
The Recommended Preventive Care Services clause defines which preventive healthcare services are covered under an insurance policy or healthcare agreement. Typically, it specifies that services such as immunizations, screenings, and annual check-ups recommended by recognized authorities (like the U.S. Preventive Services Task Force) are included without additional cost to the insured. This clause ensures that policyholders have access to essential preventive care, promoting early detection and management of health issues while reducing long-term healthcare costs.
Recommended Preventive Care Services. Annually, OMPP will determine which recommended preventive services qualify a member for roll over or discount. The Contractor shall send preventive service reminders to their members throughout the benefit period, including in the monthly POWER Account Statements and redetermination correspondence. The Contractor shall have mechanisms in place to monitor when a member has obtained the preventive care services recommended for his or her age and gender, as well as pre-existing conditions, and report this information on the PRF one hundred and twenty (120) calendar days following the end of the member’s benefit period. The Contractor shall monitor whether a member has received recommended preventive care services by:
1. Utilizing claims data to determine if any of the certain specified disease conditions exist;
2. Utilizing claims data to determine if required services have been obtained (OMPP shall provide the qualifying CPT and/or ICD-10 codes, as applicable); and
3. If, after #1 and #2, preventive services cannot be verified, the Contractor may require the member to submit verification of preventive services. Members will only be required to complete disease-specific preventive services if they were diagnosed with the disease prior to the beginning of the benefit period. If a disease develops mid-benefit period, the member will not be required to complete preventive care services related to that disease until the next benefit period. Ninety (90) calendar days prior to the end of a member’s benefit period, the Contractor shall make an initial assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. If the member has not received recommended preventive services, the Contractor shall send a reminder to the member. The reminder shall notify the member that the Contractor’s records indicate that the member has not received recommended preventive services based on medical claims received as of a specified date. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. The reminder shall also explain the appropriate roll-over incentive based on the member’s benefit plan that the member would be eligible to receive in the subsequent benefit period following completion of any recommended preventive service. This correspondence should be coordinated with other redetermination remind...