Specialty Physician Services Sample Clauses

Specialty Physician Services. Specialty physician services, ancillary services and specialty hospital services are to be available within sixty (60) minutes driving time from the Participant’s residence to provider. Driving time standards may be waived with sufficient justification if specialty care services are not obtainable due to a limitation of providers, such as in rural areas. HEALTHEASE AND STAYWELL HMO Effective Date: October 1, 2005 with the following: A. B. C. D. E. Emergency care shall be provided immediately; Urgently needed care shall be provided within twenty-four (24) hours; Routine care of patients who do not require emergency or urgently needed care shall be provided within seven (7) calendar days; Routine physical examinations shall be provided within four (4) weeks of Enrollee’s request; and Follow-up care shall be provided as medically appropriate. For the purposes of this section, the following definitions shall apply: Emergency care is that care required for the treatment of an injury or acute illness that, if not treated immediately, could reasonably result in serious or permanent damage to the patient’s health. Urgently needed care is that care required within a twenty-four (24) hour period to prevent a condition from requiring emergency care. Routine care is that level of care that can be delayed without anticipated deterioration in the patient’s medical condition for a period of seven (7) calendar days. By utilization of the foregoing standards, FHKC does not intend to create standards of care or access different from those that are deemed acceptable within the INSURER service area. Rather FHKC intends that the provider timely and appropriately respond to patient care needs, as they are presented, in accordance with standards of care existing within the service area. In applying the foregoing standards, the provider shall give due regard to the ‘evel of discomfort and anxiety of the patient and/or parent. In the event FHKC determines that INSURER, or its providers, has failed to meet the access standards herein set forth, FHKC shall provide INSURER with written notice of non-compliance. Such notice may be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow INSURER to investigate and respond. Failure of INSURER to obtain reasonable compliance or acceptable community care under the following conditions shall constitute a breach of this Agreement: A. immediately upon receipt of notice for emergency or urgent prob...
AutoNDA by SimpleDocs

Related to Specialty Physician Services

  • Physician Visits This plan covers the services of a physician or other provider in charge of your medical care while you are inpatient in a general or specialty hospital.

  • 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.

  • 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.

  • 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.

  • 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.

  • Dental Services The following dental services are not covered, except as described under Dental Services in Section 3: • Dental injuries incurred as a result of biting or chewing. • General dental services including, but not limited to, extractions including full mouth extractions, prostheses, braces, operative restorations, fillings, frenectomies, medical or surgical treatment of dental caries, gingivitis, gingivectomy, impactions, periodontal surgery, non-surgical treatment of temporomandibular joint dysfunctions, including appliances or restorations necessary to increase vertical dimensions or to restore the occlusion. • Panorex x-rays or dental x-rays. • Orthodontic services, even if related to a covered surgery. • Dental appliances or devices. • Preparation of the mouth for dentures and dental or oral surgeries such as, but not limited to, the following: o apicoectomy, per tooth, first root; o alveolectomy including curettage of osteitis or sequestrectomy; o alveoloplasty, each quadrant; o complete surgical removal of inaccessible impacted mandibular tooth mesial surface; o excision of feberous tuberosities; o excision of hyperplastic alveolar mucosa, each quadrant; o operculectomy excision periocoronal tissues; o removal of partially bony impacted tooth; o removal of completely bony impacted tooth, with or without unusual surgical complications; o surgical removal of partial bony impaction; o surgical removal of impacted maxillary tooth; o surgical removal of residual tooth roots; and o vestibuloplasty with skin/mucosal graft and lowering the floor of the mouth. • The following dialysis services received in your home: o installing or modifying of electric power, water and sanitary disposal or charges for these services; o moving expenses for relocating the machine; o installation expenses not necessary to operate the machine; and o training in the operation of the dialysis machine when the training in the operation of the dialysis machine is billed as a separate service. • Dialysis services received in a physician’s office.

  • Surgery Services This plan covers surgery services to treat a disease or injury when: • the operation is not experimental or investigational, or cosmetic in nature; • the operation is being performed at the appropriate place of service; and • the physician is licensed to perform the surgery. This plan covers reconstructive surgery and procedures when the services are performed to relieve pain, or to correct or improve bodily function that is impaired as a result of: • a birth defect; • an accidental injury; • a disease; or • a previous covered surgical procedure. Functional indications for surgical correction do not include psychological, psychiatric or emotional reasons. This plan covers the procedures listed below to treat functional impairments. • abdominal wall surgery including panniculectomy (other than an abdominoplasty); • blepharoplasty and ptosis repair; • gastric bypass or gastric banding; • nasal reconstruction and septorhinoplasty; • orthognathic surgery including mandibular and maxillary osteotomy; • reduction mammoplasty; • removal of breast implants; • removal or treatment of proliferative vascular lesions and hemangiomas; • treatment of varicose veins; or • gynecomastia.

  • Diagnostic Services All necessary procedures to assist the dentist in evaluating the existing conditions to determine the required dental treatment, including: Oral examinations Consultations

  • Medical Services We do not Cover medical services or dental services that are medical in nature, including any Hospital charges or prescription drug charges.

  • Hospital Services The Hospital will: 6.1.1 achieve the Performance Standards described in the Schedules and the HSAA Indicator Technical Specifications; 6.1.2 not reduce, stop, start, expand, cease to provide or transfer the provision of Hospital Services to another hospital or to another site of the Hospital if such action would result in the Hospital being unable to achieve the Performance Standards described in the Schedules and the HSAA Indicator Technical Specifications; and 6.1.3 not restrict or refuse the provision of Hospital Services that are funded by the Funder to an individual, directly or indirectly, based on the geographic area in which the person resides in Ontario, and will establish a policy prohibiting any health care professional providing services at the Hospital, including physicians, from doing the same.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!