Services to Members. Provider, within the limitations of Michigan licensure laws, will provide Covered Services to Members based on requirements in Members’ Certificates, BCBSM Medical Necessity criteria as set forth in Addendum A, and as governed by this Agreement and all other BCBSM policies in effect on the dates Covered Services are provided.
Services to Members. Subject at all times to the terms of this Agreement, IPA agrees to provide or arrange for medical and related health care services to individuals designated by Humana (herein referred to as “Members”) with an identification card or other means of identifying them as Members covered under a self-funded or fully insured health benefits plan to which IPA has agreed to participate as set forth in the product participation list attachment.
Services to Members. Provider, within the limitations of any applicable state licensure laws, shall provide Covered Services to Members as set forth in Certificates. Provider certifies that all services billed or reported by Provider are within the scope of the rendering healthcare practitioner’s scope of practice or license, if applicable, and are performed personally by the healthcare practitioner, or under his/her direct supervision as defined by BCBSM, or except as otherwise authorized and communicated in writing by BCBSM, and are submitted in accordance with the terms and conditions of the Members' Certificates. Provider will adhere to all BCBSM published guidelines for the provision and billing of Covered Services to Members.
Services to Members. 8.1 Subject at all times to the terms of this Agreement, Physician agrees to provide Physician Services or to arrange for professional medical service and/or related health care services to VHP Members with an identification card or other means of identifying them as Members covered under a self-funded or fully insured health benefits plan to which Physician has agreed to participate as set forth in the Product Participation List in Attachment 1.
8.2 Physician agrees to provide health care services to individuals covered under other third-party payors' (hereinafter referred to as "Payor" or "Payors") health benefits contracts (hereinafter referred to as "Plan" or "Plans") and agrees to comply with such Payors' policies and procedures. For Covered Services rendered to such individuals, Physician acknowledges and agrees that all rights and responsibilities arising with respect to benefits to such individuals shall be subject to the terms of the Payor Plan covering such individuals. Individuals covered under such Plans will have an identification card as a means of identifying the Payor Plan which provides coverage.
8.3 For Covered Services provided to those individuals identified in Section 8.2 above, Payor will make payments for Covered Services directly to Physician in accordance with the terms and conditions of this Agreement and the rates set forth in the Payment Terms Attachment 2 applicable to the Plan type of such individual. Physician agrees that in no event, including, but not limited to, nonpayment by Payor, or Payor's insolvency, shall Physician xxxx, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against VHP for services provided by Physician to Plans' members. This provision shall not prohibit collection by Physician from Plans' members for non-covered services and/or member cost share amounts in accordance with the terms of the applicable member Plan. All obligations of Physician under this Agreement with respect to VHP's Members shall equally apply to the individuals identified in Section 8.2 above.
Services to Members to provide certain services to the Members as may be required; and
Services to Members. In the event Physician provides a Member a non-covered service or refers a Member to an out-of-network provider without pre-authorization from Humana, Physician shall, prior to the provision of such non-covered service or out-of-network referral, inform the Member: (i) of the service(s) to be provided or referral(s) to be made; (ii) that Humana will not pay or be liable financially for such non-covered service(s) or out-of-network referral(s); and (iii) that Member will be responsible financially for non-covered service(s) and/or out-of-network referral(s) that are requested by the Member.
Services to Members. Each Member hereby acknowledges and recognizes that the Company has retained, and may in the future retain, the services of various professionals, including general and special legal counsel, accountants, architects and engineers, for the purposes of representing and providing services to the Company in the investigation, analysis, acquisition, development, renting, marketing and operation of the Company Assets, or otherwise. Each Member hereby acknowledges that such persons or entities may have in the past represented and performed and currently and/or may in the future represent or perform services for certain of the Members or their Affiliates. Accordingly, each Member and the Company consents to the performance by such persons or entities of services for the Company and waives any right to claim a conflict of interest based on such past or present representation or services to any of the Members or their Affiliates.
Services to Members a. The MCO shall have in place an ongoing process of Member education which includes, but is not limited to: development of a Member handbook; provider directory; newsletter; and other Member educational materials. All written materials and correspondence to Members shall be culturally sensitive and written at no higher than a seventh grade reading level. All Member educational materials must be in both English and Spanish.
b. The MCO shall mail the Member handbook and provider directory to Members within one week of enrollment notification. The Member handbook shall address and explain, at a minimum, the following:
1. Covered services;
2. Restrictions on services (including limitations and services not covered):
3. Prior authorization process;
4. Definition of and distinction between emergency care and urgent care;
5. Policies on the use of emergency and urgent care services including a phone number which can be used for assistance in obtaining urgent care;
6. How to access care twenty-four (24) hours a day;
7. Assistance with appointment scheduling;
8. Member rights and responsibilities;
9. Member services, including hours of operation;
10. Enrollment/disenrollment/plan changes;
11. Procedures for selecting and changing PCPs;
12. Availability of provider network directory and updates;
13. That a Member is not liable for copayments;
14. Limited liability for services from out-of-network providers;
15. Access and availability standards;
16. Special access and other MCO features of the health plan's program;
17. Family planning services;
18. Case management services targeted to Members as medically necessary and appropriate;
19. The MCO's grievance and the DEPARTMENT's administrative hearing process;
20. Procedures to request non-emergency transportation and transportation options;
21. EPSDT services for children;
22. Coordination of benefits and third party liability; and
23. Description of drug formulary, prior approval and override process, if applicable.
c. All Member educational materials must be prior approved by the DEPARTMENT. Educational materials include, but are not limited to: Member handbook; Membership card; introductory and other text language from the provider directory; and all communications to Members that include HUSKY A program information. The MCO must wait until receiving DEPARTMENT written approval or thirty (30) days from the date of submittal before disseminating educational materials to Members. The DEPARTMENT reserves the right t...
Services to Members. Provider, within the limitations of state licensure laws, will provide Covered Services to Members as set forth in Certificates.
Services to Members. Facility, within the limitations of its BCBSM approval, and its state licensure laws, will provide Covered Services to Members in exchange for reimbursement from BCBSM pursuant to Section 3.5 of, and as governed by the terms and conditions of this Agreement and all other published BCBSM policies in effect on the dates Covered Services are provided.
