SPECIAL COVERAGE PROVISIONS Sample Clauses
The "Special Coverage Provisions" clause defines specific terms and conditions under which additional or unique insurance coverage is provided beyond the standard policy. This clause may outline particular situations, types of property, or risks that are covered, such as coverage for valuable items, natural disasters, or other non-standard events. By detailing these special circumstances, the clause ensures that both the insurer and the insured are clear about the extent and limitations of coverage, thereby reducing ambiguity and potential disputes over what is protected under the policy.
SPECIAL COVERAGE PROVISIONS. If funds are appropriated the following sub-sections describe special considerations, services, and/or funding arrangements required by this contract. The parties recognize that some persons served under these special considerations, services or arrangements may be Medicaid beneficiaries, and that the CMHSP may discharge its obligations and service provision responsibilities specified below to such individuals using both general funds dollars and available Medicaid specialty service benefits and coverages.
SPECIAL COVERAGE PROVISIONS. The following sub-sections describe special considerations, services, and/or funding arrangements that may be required by this contract.
SPECIAL COVERAGE PROVISIONS. The PSN shall provide the following services in accordance with the provisions herein, and in accordance with the Florida Medicaid Coverage and Limitations Handbooks and the Florida Medicaid State Plan. The PSN shall comply with all State and federal laws pertaining to the provision of such services. Enrollees who require services available through Medicaid that are not Covered Services by the terms of this Contract shall receive those services through the Medicaid Fee-for-Service reimbursement system.
SPECIAL COVERAGE PROVISIONS. 4.6.1 Emergency Services
4.6.1.1 Emergency Services shall be available twenty-four (24) hours a day, seven (7) Days a week to treat an Emergency Medical Condition.
4.6.1.2 An Emergency Medical Condition shall not be defined or limited based on a list of diagnoses or symptoms. An Emergency Medical Condition is a medical or mental health Condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
4.6.1.2.1 Placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
4.6.1.2.2 Serious impairment to bodily functions;
4.6.1.2.3 Serious dysfunction of any bodily organ or part;
4.6.1.2.4 Serious harm to self or others due to an alcohol or drug abuse emergency;
4.6.1.2.5 Injury to self or bodily harm to others; or
4.6.1.2.6 With respect to a pregnant woman having contractions: (i) that there is adequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.
4.6.1.3 The Contractor shall provide payment for Emergency Services when furnished by a qualified Provider, regardless of whether that Provider is in the Contractor’s network. These services shall not be subject to prior authorization requirements. The Contractor shall be required to pay for all Emergency Services that are Medically Necessary until the Member is stabilized. The Contractor shall also pay for any screening examination services conducted to determine whether an Emergency Medical Condition exists.
4.6.1.4 The Contractor shall base coverage decisions for Emergency Services on the severity of the symptoms at the time of presentation and shall cover Emergency Services when the presenting symptoms are of sufficient severity to constitute an Emergency Medical Condition in the judgment of a prudent layperson.
4.6.1.5 The attending emergency room physician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor, who shall be responsible for coverage and payment. The Contractor, however, may establish arrangements with a hospital whereby the Contra...
SPECIAL COVERAGE PROVISIONS. Revised 5/19/2008
SPECIAL COVERAGE PROVISIONS