Services Not Medically Necessary Sample Clauses

Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, behavioral health services, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary. We will use any reasonable means to make a determination about the medical necessity of this care. We may look at medical records, reports and utilization review committee statements. We review medical necessity in accordance with our medical policies and related guidelines. You have the right to appeal our determination or to take legal action as described in Section 7.0. We may deny payments if a doctor or hospital does not supply medical records needed to determine medical necessity. We may also deny or reduce payment if the records sent to us do not provide adequate justification for performing the service. This agreement does NOT cover routine screenings or tests performed by a hospital which are not medically necessary for the diagnosis or treatment of your condition. This agreement does NOT cover routine screenings or tests which are not specifically ordered by the doctor who admits you.
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Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines.  Services Not Performed Within Indicated Time Limitations - Dental services performed that do not comply with the timeframes and limitations as set forth in this agreement and in our dental policies and related guidelines are NOT covered.  Anesthesia - General anesthesia and intravenous sedation are NOT covered unless rendered in conjunction with covered oral surgical procedures. Covered dental care services excludes the services of an anesthesiologist.  Cosmetic Services - This agreement does NOT cover cosmetic procedures. Cosmetic procedures are performed to refine or reshape dental structures that are not functionally impaired, to change or improve appearance or improve self-esteem, or for other psychological, psychiatric or emotional reasons.  Implants - This agreement does NOT cover dental implants, implant support prosthesis, or other implant related services, except for a single tooth implants which are covered as a prosthodontic service if placed as an alternative treatment to a conventional 3-unit bridge, replacing only one missing tooth with sound natural teeth on either side.  Experimental/investigational Services - This agreement does NOT cover experimental or investigational procedures or services. Experimental or investigational procedures or services are not included in our dental policies and related guidelines. Experimental or investigational means any dental procedure that has progressed to limited human application, but has not been recognized as clinically proven and effective.  Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen.  New Dental Services - This agreement does NOT cover any new dental procedures or services that are not included in our dental policies and related guidelines.  Services Performed By Hospital Staff Employees - This agreement does NOT cover pediatric dental services rendered at a hospital by interns, residents, or staff dentists.  Specialty Oral Examinations - We will NOT cover oral examinations (limited in scope) when performed by a dentist who limits his or her practice to a specialty branch of dentistry. This includes, but is not limited to, oral examinations relating to periodontics, orthodontics, endodontics, oral surgery, and prosthodontics.  Temporomandibular Joint Syndr...
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Services Not Medically Necessary. Payment will be denied for services provided by Group that BlueLincs HMO determines to be not Medically Necessary or Experimental/Investigational/Unproven. Such denied charges may not be collected from the BlueLincs HMO Member.
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Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which we determine is NOT medically necessary. (See Section 7.0 - Glossary). We have the right and discretionary authority to use any reasonable means to determine the medical necessity of this care and we may examine hospital records, reports and hospital utilization review committee statements. We have the right to deny payments if a doctor or hospital does not supply medical records required to determine medical necessity. We also have the right to deny or reduce payment if the records supplied do not provide adequate justification for performing the service. If the hospital performs routine screenings or tests which are not medically necessary for the diagnosis or treatment of your condition or which are not specifically ordered by the doctor who admits you, this agreement does NOT cover them.
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Services Not Medically Necessary. This agreement does NOT cover orthodontic services that are NOT medically necessary in accordance with our policies and guidelines. • Replacement Services - This agreement does NOT cover orthodontic or prosthetic appliances and space maintainers that are misplaced, lost, or stolen. See Section 4.18 for other Dental Services not covered under this agreement.
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Services Not Medically Necessary. This agreement does NOT cover hospital care (admission tests, services, supplies, or continued care), medical care, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which is NOT medically necessary.
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Related to Services Not Medically Necessary

  • Information and Services Required of the Owner The Owner shall provide information with reasonable promptness, regarding requirements for and limitations on the Project, including a written program which shall set forth the Owner’s objectives, constraints, and criteria, including schedule, space requirements and relationships, flexibility and expandability, special equipment, systems, sustainability and site requirements.

  • Information Services Traffic 5.1 For purposes of this Section 5, Voice Information Services and Voice Information Services Traffic refer to switched voice traffic, delivered to information service providers who offer recorded voice announcement information or open vocal discussion programs to the general public. Voice Information Services Traffic does not include any form of Internet Traffic. Voice Information Services Traffic also does not include 555 traffic or similar traffic with AIN service interfaces, which traffic shall be subject to separate arrangements between the Parties. Voice Information services Traffic is not subject to Reciprocal Compensation charges under Section 7 of the Interconnection Attachment. 5.2 If a D&E Customer is served by resold Verizon Telecommunications Service or a Verizon Local Switching UNE, subject to any call blocking feature used by D&E, to the extent reasonably feasible, Verizon will route Voice Information Services Traffic originating from such Service or UNE to the Voice Information Service platform. For such Voice Information Services Traffic, unless D&E has entered into an arrangement with Verizon to xxxx and collect Voice Information Services provider charges from D&E’s Customers, D&E shall pay to Verizon without discount the Voice Information Services provider charges. D&E shall pay Verizon such charges in full regardless of whether or not it collects such charges from its own Customers. 5.3 D&E shall have the option to route Voice Information Services Traffic that originates on its own network to the appropriate Voice Information Services platform(s) connected to Verizon’s network. In the event D&E exercises such option, D&E will establish, at its own expense, a dedicated trunk group to the Verizon Voice Information Service serving switch. This trunk group will be utilized to allow D&E to route Voice Information Services Traffic originated on its network to Verizon. For such Voice Information Services Traffic, unless D&E has entered into an arrangement with Verizon to xxxx and collect Voice Information Services provider charges from D&E’s Customers, D&E shall pay to Verizon without discount the Voice Information Services provider charges. 5.4 D&E shall pay Verizon such charges in full regardless of whether or not it collects charges for such calls from its own Customers. 5.5 For variable rated Voice Information Services Traffic (e.g., NXX 550, 540, 976, 970, 940, as applicable) from D&E Customers served by resold Verizon Telecommunications Services or a Verizon Local Switching Network Element, D&E shall either (a) pay to Verizon without discount the Voice Information Services provider charges, or (b) enter into an arrangement with Verizon to xxxx and collect Voice Information Services provider charges from D&E’s Customers. 5.6 Either Party may request the other Party provide the requesting Party with non discriminatory access to the other party’s information services platform, where such platform exists. If either Party makes such a request, the Parties shall enter into a mutually acceptable written agreement for such access. 5.7 In the event D&E exercises such option, D&E will establish, at its own expense, a dedicated trunk group to the Verizon Information Service serving switch. This trunk group will be utilized to allow D&E to route information services traffic originated on its network to Verizon.

  • Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.

  • Outpatient Services Physicians, Urgent Care Centers and other Outpatient Providers located outside the BlueCard® service area will typically require You to pay in full at the time of service. You must submit a Claim to obtain reimbursement for Covered Services.

  • Inpatient Services Hospital Rehabilitation Facility

  • Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.

  • Related Services Licensee shall be responsible for obtaining and installing all proper hardware and support software (including operating systems) and for proper installation and implementation of and training concerning the Licensed Software. In the event that Licensee retains Licensor to perform any services with respect to the Licensed Software (for example: installation, implementation, maintenance, consulting and/or training services), Licensee and Licensor agree that such services shall be subject to Licensor’s then current standard terms, conditions and rates for such services unless otherwise agreed in writing by Licensor.

  • Preventive Services All necessary procedures to prevent the occurrence of oral disease, including: Cleaning and scaling Topical application of fluoride Space maintainers

  • Chiropractic Services This plan covers chiropractic visits up to the benefit limit shown in the Summary of Medical Benefits. The benefit limit applies to any visit for the purposes of chiropractic treatment or diagnosis.

  • Anesthesia Services This plan covers general and local anesthesia services received from an anesthesiologist when the surgical procedure is a covered healthcare service. This plan covers office visits or office consultations with an anesthesiologist when provided prior to a scheduled covered surgical procedure.