Common use of Timely Treatment Clause in Contracts

Timely Treatment. Timely treatment by providers, such that the participant shall be seen by a provider in accordance with the following: A. Emergency care shall be provided immediately; B. Urgently needed care shall be provided within twenty-four (24) hours; C. Routine care of patients who do not require emergency or urgently needed care shall be provided within seven (7) calendar days; D. Follow-up care shall be provided as medically appropriate. For the purposes of this section, the following definitions shall apply: Emergency care is that 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 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 HEALTH PLAN 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 level of discomfort and anxiety of the patient and/or parent. In the event FHKC determines that HEALTH PLAN, or its providers, has failed to meet the access standards herein set forth, FHKC shall provide HEALTH PLAN with written notice of non-compliance. Such notice can be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow HEALTH PLAN to investigate and respond. Failure of HEALTH PLAN 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 problem; or B. within ten (10) days of receipt of notice for routine visit access. Such breach shall entitle FHKC to such legal and equitable relief as may be appropriate. In particular, FHKC may direct its participants to obtain such services outside HEALTH PLAN HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 40 of 50 provider network as specified in Section 3-2-1 of this Agreement. HEALTH PLAN shall be financially responsible for all services under this provision. HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 41 of 50 EXHIBIT F ELIGIBILITY STANDARDS PARTICIPANT ELIGIBILITY CRITERIA The following eligibility criteria for participation in the Healthy Kids Program must be met: 1. The participants must be children who are age 5 through 18. Participants who applied for coverage prior to July 1, 1998 are eligible for coverage through their 19th birthday. For Escambia, Xxxxx and Highlands counties, some children may have age eligibility from age 1 to 5 based on date of application to the program. For Broward, Miami-Dade, Palm Beach and Pinellas some children may have age eligibility from age 3 to 5 based on date of application to the program. 2. Participants must meet the eligibility criteria established under Section 624.91, Florida Statutes, and as implemented by FHKC Board of Directors. 3. Eligible participants may enroll during time periods established by FHKC Board of Directors and in accordance with Section 624.91, Florida Statutes. HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 EXHIBIT G REPORTING REQUIREMENTS HEALTH PLAN shall provide the following reports and data tapes to FHKC according to the time schedules detailed below. This information shall include all services provided by HEALTH PLAN'S subcontractors. HEALTH PLAN is responsible for ensuring that all subcontractors comply with these reporting requirements.

Timely Treatment. Timely treatment by providers, such that the participant shall be seen by a provider in accordance with the following: A. Emergency care shall be provided immediately; B. Urgently needed care shall be provided within twenty-four (24) hours; C. Routine care of patients who do not require emergency or urgently needed care shall be provided within seven (7) calendar days; D. Physical examinations shall be provided within four (4) weeks of request for appointment; and E. Follow-up care shall be provided as medically appropriate. For the purposes of this section, the following definitions shall apply: Emergency care is that required for the treatment of an injury or acute illness thatwhich, if not treated immediately, could reasonably result in serious or permanent damage to the patient's health. Urgently needed care is that required within a twenty-four (24) hour period to prevent a condition from requiring emergency care. Routine care is that level of care that which can be delayed without anticipated deterioration in the patient's medical condition for a period of seven (7) calendar days. PHP HEALTH PLAN OF FLORIDA\Palm Beach Page 34 of 43 EXHIBIT E (Continued) By utilization of the foregoing standards, FHKC does not intend to create standards of care or access different from those that which are deemed acceptable within HEALTH PLAN the PHP 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 level of discomfort and anxiety of the patient and/or parent. In the event FHKC determines that HEALTH PLANPHP, or its providers, has failed to meet the access standards herein set forth, FHKC shall provide HEALTH PLAN PHP with written notice of non-compliance. Such notice can be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow HEALTH PLAN PHP to investigate and respond. Failure of HEALTH PLAN PHP 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 problem; or B. within ten (10) days of receipt of notice for routine visit access. Such breach shall entitle FHKC to such legal and equitable relief as may be appropriate. In particular, FHKC may direct its participants to obtain such services outside HEALTH PLAN HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 40 of 50 the PHP provider network as specified in Section 3-2-1 of this Agreementnetwork. HEALTH PLAN PHP shall be financially responsible for all services under this provision. HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 41 of 50 EXHIBIT F ELIGIBILITY STANDARDS PARTICIPANT ELIGIBILITY CRITERIA The following eligibility criteria for participation GRIEVANCE, ARBITRATION AND LEGAL PROCESS X. XXXXXXXXX AND ARBITRATION Complaints or disputes which do not involve allegations of "medical negligence" against a health care provider as defined in the Healthy Kids Program must be met: 1. The participants must be children who are age 5 through 18. Participants who applied for coverage prior to July 1, 1998 are eligible for coverage through their 19th birthday. For Escambia, Xxxxx and Highlands counties, some children may have age eligibility from age 1 to 5 based on date of application to the program. For Broward, Miami-Dade, Palm Beach and Pinellas some children may have age eligibility from age 3 to 5 based on date of application to the program. 2. Participants must meet the eligibility criteria established under Section 624.91Chapter 768, Florida Statutes, shall be subject to grievance and arbitration as hereinafter set forth: Initiation of Complaint: If a participant's complaint cannot be resolved satisfactorily on an informal basis, the participant shall complete and submit to PHP, a grievance form recording the participant's name, address, telephone number, client number and as implemented by FHKC Board of Directors. 3. Eligible participants may enroll during time periods established by FHKC Board of Directors and in accordance with Section 624.91, Florida Statutes. HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 EXHIBIT G REPORTING REQUIREMENTS HEALTH PLAN shall provide the following reports and data tapes to FHKC according many facts as possible related to the time schedules detailed belowproblem (date, time, people, circumstances, etc.). This information The completed form shall include all services provided by HEALTH PLAN'S subcontractors. HEALTH PLAN is responsible for ensuring that all subcontractors comply be filed with these reporting requirementsthe PHP Member Relations Counselor (MRC) within sixty (60) days from the date the problem occurred.

Timely Treatment. Timely treatment by providers, such that the participant shall be seen by a provider in accordance with the following: A. Emergency care shall be provided immediately; B. Urgently needed care shall be provided within twenty-four (24) hours; C. Routine care of patients who do not require emergency or urgently needed care shall be provided within seven (7) calendar days; D. Follow-up care shall be provided as medically appropriate. For the purposes of this section, the following definitions shall apply: Emergency care is that 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 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 HEALTH PLAN AMERIGROUP 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 level of discomfort and anxiety of the patient and/or parent. In the event FHKC determines that HEALTH PLANAMERIGROUP, or its providers, has failed to meet the access standards herein set forth, FHKC shall provide HEALTH PLAN AMERIGROUP with written notice of non-compliance. Such notice can be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow HEALTH PLAN AMERIGROUP to investigate and respond. Failure of HEALTH PLAN AMERIGROUP 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 problem; or B. within ten (10) days of receipt of notice for routine visit access. Such breach shall entitle FHKC to such legal and equitable relief as may be appropriate. In particular, FHKC may direct its participants to obtain such services outside HEALTH PLAN HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 40 of 50 AMERIGROUP provider network as specified in Section 3-2-1 of this Agreement. HEALTH PLAN AMERIGROUP shall be financially responsible for all services under this provision. HEALTH PLANS AMERIGROUP Effective DatesDate: October 1, 2003 - September 30, 2005 Page 41 38 of 50 45 EXHIBIT F ELIGIBILITY STANDARDS PARTICIPANT ELIGIBILITY CRITERIA The following eligibility criteria for participation in the Healthy Kids Program must be met: 1. The participants must be children who are age 5 through 18. Participants who applied for coverage prior to July 1, 1998 are eligible for coverage through their 19th birthday. For Escambia, Xxxxx and Highlands counties, some children may have age eligibility from age 1 to 5 based on date of application to the program. For Broward, Miami-Dade, Palm Beach and Pinellas some children may have age eligibility from age 3 to 5 based on date of application to the program. 2. Participants must meet the eligibility criteria established under Section 624.91, Florida Statutes, and as implemented by FHKC Board of Directors. 3. Eligible participants may enroll during time periods established by FHKC Board of Directors and in accordance with Section 624.91, Florida Statutes. HEALTH PLANS AMERIGROUP Effective DatesDate: October 1, 2003 - September 30, 2005 EXHIBIT G REPORTING REQUIREMENTS HEALTH PLAN AMERIGROUP shall provide the following reports and data tapes to FHKC according to the time schedules detailed below. This information shall include all services provided by HEALTH PLANAMERIGROUP'S subcontractors. HEALTH PLAN AMERIGROUP is responsible for ensuring that all subcontractors comply with these reporting requirements.

Timely Treatment. Timely treatment by providers, such that the participant Participant shall be seen by a provider in accordance AMERIGROUP FLORIDA, INC. Effective Date: October 1, 2005 with the following: A. Emergency care shall be provided immediately; B. Urgently needed care shall be provided within twenty-four (24) hours; C. Routine care of patients who do not require emergency or urgently needed care shall be provided within seven (7) calendar days; D. Routine physical examinations shall be provided within four (4) weeks of Enrollee's request; and E. 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 HEALTH PLAN 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 level of discomfort and anxiety of the patient and/or parent. In the event FHKC determines that HEALTH PLANINSURER, or its providers, has failed to meet the access standards herein set forth, FHKC shall provide HEALTH PLAN INSURER with written notice of non-compliance. Such notice can may be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow HEALTH PLAN INSURER to investigate and respond. Failure of HEALTH PLAN INSURER to obtain reasonable compliance or acceptable community care under the following conditions shall constitute a breach of this agreementAgreement: A. immediately upon receipt of notice for emergency or urgent problem; orOF B. within ten (10) days of receipt of notice for routine visit access. Such breach shall entitle FHKC to such legal and equitable relief as may be appropriate. In particular, FHKC may direct its participants Participants to obtain such services outside HEALTH PLAN HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 40 of 50 provider the Insurer Provider network as specified in Section 3-2-1 of this Agreement. HEALTH PLAN INSURER shall be financially responsible for all services under this provision. HEALTH PLANS AMERIGROUP FLORIDA, INC. Effective DatesDate: October 1, 2003 - September 30, 2005 Page 41 of 50 EXHIBIT F ELIGIBILITY STANDARDS PARTICIPANT ELIGIBILITY CRITERIA The following eligibility criteria for participation in the Healthy Kids Program must be met: 1. : The participants Participants must be children who are age 5 through 18. Participants who applied for coverage prior to July 1, 1998 1998, and who had attained the age of 19 by March 31, 2004, are eligible for coverage through their 19th birthday. For Escambia, Xxxxx and Highlands countiesIn accordance with the terms of the Request for Proposals dated April 2004, some children may have age eligibility from age 1 to 5 based 18 months through age 4, depending on date their county of application to the program. For Broward, Miami-Dade, Palm Beach and Pinellas some children may have age eligibility from age 3 to 5 based on date of application to the programresidence. 2. Participants must meet the eligibility criteria established under Section 624.91, Florida Statutes, and as implemented by FHKC Board of Directors. 3. Eligible participants may enroll during time periods established by FHKC Board of Directors and in accordance with Section 624.91, Florida Statutes. HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 EXHIBIT G REPORTING REQUIREMENTS HEALTH PLAN shall provide the following reports and data tapes to FHKC according to the time schedules detailed below. This information shall include all services provided by HEALTH PLAN'S subcontractors. HEALTH PLAN is responsible for ensuring that all subcontractors comply with these reporting requirements.

Timely Treatment. Timely treatment by providers, such that the participant shall be seen by a provider in accordance with the following: A. Emergency care shall be provided immediately; ; B. Urgently needed care shall be provided within twenty-four (24) hours; ; C. Routine care of patients who do not require emergency or urgently needed care shall be provided within seven (7) calendar days; ; D. Follow-up care shall be provided as medically appropriate. PHP/Pasco and Polk Effective Date: October 1, 2002 Page 35 of 41 For the purposes of this section, the following definitions shall apply: Emergency care is that 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 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 HEALTH PLAN the PHP 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 level of discomfort and anxiety of the patient and/or parent. In the event FHKC determines that HEALTH PLANPHP, or its providers, has failed to meet the access standards herein set forth, FHKC shall provide HEALTH PLAN PHP with written notice of non-compliance. Such notice can be provided via facsimile or other means, specifying the failure in such detail as will reasonably allow HEALTH PLAN PHP to investigate and respond. Failure of HEALTH PLAN PHP 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 problem; or or B. within ten (10) days of receipt of notice for routine visit access. Such breach shall entitle FHKC to such legal and equitable relief as may be appropriate. In particular, FHKC may direct its participants to obtain such services outside HEALTH PLAN HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 Page 40 of 50 the PHP provider network as specified in Section 3-2-1 of this Agreementnetwork. HEALTH PLAN PHP shall be financially responsible for all services under this provision. HEALTH PLANS PHP/Pasco and Polk Effective DatesDate: October 1, 2003 - September 30, 2005 2002 Page 36 of 41 of 50 EXHIBIT F ELIGIBILITY STANDARDS PARTICIPANT ELIGIBILITY CRITERIA Participant Eligibility Criteria The following eligibility criteria for participation in the Healthy Kids Program must be met: 1. : The participants must be children who are age 5 through 18. Participants , and the following groups are also eligible: Children who applied for received coverage prior to July October 1, 1998 are will be eligible for coverage through their 19th birthday. For Escambia, Xxxxx and Highlands counties, some children may have age eligibility from age 1 to 5 based on date of application to the program. For Broward, Miami-Dade, Palm Beach and Pinellas some children may have age eligibility from age 3 to 5 based on date of application to the program. 2. Participants must meet the eligibility criteria established under Section 624.91, Florida Statutes, and as implemented by FHKC Board of Directors. 3. Eligible participants may enroll during time periods established by FHKC Board of Directors and in accordance with Section 624.91, Florida Statutes. HEALTH PLANS Effective Dates: October 1, 2003 - September 30, 2005 EXHIBIT G REPORTING REQUIREMENTS HEALTH PLAN shall provide the following reports and data tapes to FHKC according to the time schedules detailed below. This information shall include all services provided by HEALTH PLAN'S subcontractors. HEALTH PLAN is responsible for ensuring that all subcontractors comply with these reporting requirements.