Common use of Scope of Covered Services Clause in Contracts

Scope of Covered Services. (A) Except as otherwise provided for cases of Emergency Services, the Contractor is responsible to pay for all Covered Services listed in Attachment C. The Contractor shall also be responsible to pay for Covered Services that are, subsequent to the execution of this contract, deemed Covered Services due to amendments, revisions, or additions to the CHIP State Plan or to State or Federal regulations, guidelines or policies or made pursuant to court or administrative orders. (B) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished. (C) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiary. (D) The Contractor is responsible for payment of Emergency Services 24 hours a day, 7 days a week whether the services were provided by a Participating Provider or a Non-Participating Provider and whether the service was provided inside or outside of the Contractor’s Service Area.

Scope of Covered Services. (A) Except as otherwise provided for cases of Emergency Services, the Contractor is responsible to pay for all Covered Services listed in Attachment C. The Contractor shall also be responsible to pay for Covered Services that are, subsequent to the execution of this contract, deemed Covered Services due to amendments, revisions, or additions to the CHIP State Plan or to State or Federal regulations, guidelines or policies or made pursuant to court or administrative orders. (B) The Contractor shall ensure that services are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished. (C) The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the beneficiaryEnrollee. (D) The Contractor is responsible for payment of Emergency Services 24 hours a day, 7 days a week whether the services were provided by a Participating Provider or a Non-Participating Provider and whether the service was provided inside or outside of the Contractor’s Service Area.