Substantial Financial Risk definition

Substantial Financial Risk means a physician or physician group as defined in this Section is at substantial financial risk when more than twenty-five percent (25%) of the total maximum potential payments to the physician or physician group depend on the use of referral services. When the panel size is fewer than 25,000 enrollees’ arrangements that cause substantial financial risk include, but are not limited to, the following:
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Substantial Financial Risk means a financial risk set at greater than twenty-five percent (25%) of potential payments for Covered Services, regardless of the frequency of assessment (i.e., collection) or distribution of payments. The term “potential payments” means simply the maximum anticipated total payments that the physician or physician group could receive if the use or cost of referral services were significantly low. 42 CFR §§438.3(i), 422.208, 422.210.
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Substantial Financial Risk has the meaning specified in 42 C.F.R. (S)417.479, -------------------------- as amended from time to time.
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Examples of Substantial Financial Risk in a sentence

  • As required by Exhibit H of the OHP Contract, if Subcontractor participates in a Practitioner Incentive Plan under the Agreement that places Subcontractor at Substantial Financial Risk, Subcontractor shall maintain PIP Stop-Loss Protection.

  • Provider or provider groups are subject to requirements outlined in the Final Rule if determined to be at Substantial Financial Risk (SFR).

  • Provider must disclose annually to Health Plan and Subcontractor any PIP or risk arrangements Provider may have with physicians either within its group practice or other physicians not associated with the group practice even if there is no Substantial Financial Risk between Health Plan or Subcontractor and the physician or physician group.

  • For any subcontractor at financial risk, as defined in the Substantial Financial Risk provision, or of the Risk provision found in the Definitions Section of this Contract, the Contractor shall establish, enforce and monitor solvency requirements that provide assurance of the subcontractor's ability to meet its obligations.

  • For any subcontractor at financial risk, as described in Section 8.8.3. Substantial Financial Risk, or Section 1.17.

  • Substantial Financial Risk — Financial risk set at greater than twenty-five percent (25%) of potential payments for covered services, regardless of the frequency of assessment (i.e., collection) or distribution of payments.

  • PH-MCOs that have PIPs placing a physician or physician group at Substantial Financial Risk for the cost of services the physician or physician group does not furnish must assure that the physician or physician group has adequate Stop-Loss Protection.

  • PH-MCOs are only permitted to operate PIPs if 1) no specific payment is made directly or indirectly to a physician or physician group as an inducement to reduce or limit Medically Necessary services furnished to a Member; and 2) the disclosure, computation of Substantial Financial Risk, Stop- Loss Protection, and Member survey requirements of this section are met.

  • If Provider has agreed to provide medical service to a Member for a capitation payment, fixed fee, or other arrangement that imposes Substantial Financial Risk on Provider, Provider must protect itself against loss by maintaining a stop loss protection as required by 42 CFR 422.208 and 422.210 (“Physician Incentive Plan Regulations”) and the CCO Contract.

  • If CCO Provider participates in a Practitioner Incentive Plan under the Agreement that places CCO Provider at Substantial Financial Risk, CCO Provider shall submit stop-loss documentation to WVCH in accordance with WVCH’s policies and procedures.


More Definitions of Substantial Financial Risk

Substantial Financial Risk means financial risk achieved through capitation or the creation of significant financial incentives for the group to achieve specified cost- containment goals, such as withholding from all members a substantial amount of the compensation due to them, with distribution of that amount to the members or owners only if the cost-containment goals are met.
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Substantial Financial Risk means financial risk such as that achieved when an organization receives revenue through capitation or payment of insurance premiums, or when the organization creates significant financial incentives for providers to achieve specific cost containment goals, such as withholding a substantial amount of their compensation, with distribution of that amount made only if the cost-containment goals are met.
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Substantial Financial Risk means a financial risk set at greater than twenty-five percent (25%) of potential payments for Covered Services, regardless of the frequency of assessment (i.e., collection) or distribution of payments. The term “potential payments” means simply the maximum anticipated total payments that the physician or physician group could receive if the use or cost of referral services were significantly low. 42 CFR §§438.6(g), 422.208, 422.210. Provider Discrimination Prohibited. ACIA may not, with respect to Provider compensation or indemnification under this Agreement, discriminate against Provider to the extent that the Provider is acting within the scope of his, her or its license or certification under applicable State law, solely on the basis of that license or certification. Without limiting the foregoing, ACIA shall not discriminate against Provider for serving high-risk populations or specializing in conditions that require costly treatment. Nothing herein shall be construed to: (i) require ACIA to contract with Provider if not necessary to meet the needs of Members; (ii) preclude ACIA from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or (iii) preclude ACIA from establishing measures that are designed to maintain quality of services and control costs and are consistent with ACIA’s responsibilities to Members. 42 CFR §438.12.
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Substantial Financial Risk means a physician or Physician Group at Substantial Financial Risk when more than twenty-five percent (25%) of the total maximum potential payments to the physician or Physician Group depend on the use of referral services. When the panel size is fewer than 25,000 Enrollees’ arrangements that cause Substantial Financial Risk include, but are not limited to the following:
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Related to Substantial Financial Risk

  • high risk breach means that the threshold for notifying the individual is higher than that for notifying the relevant supervisory authority.

  • Substantial U.S. Market Interest means “substantial U.S. market interest” as that term is defined in Regulation S;

  • Minimal risk means that the probability and magnitude of harm or discomfort anticipated in the research are not greater in and of themselves than those ordinarily encountered in daily life or during the performance of routine physical or psychological examinations or tests.

  • Substantial disruption means without limitation that any one or more of the following occur as a result of the bullying:

  • Substantial Change means a change to the terms of this Agreement that reduces your rights or increases your responsibilities.

  • fall risk means any potential exposure to falling either from, off or into;

  • operational risk means the risk of loss resulting from inadequate or failed internal processes, people and systems or from external events, and includes legal risk;

  • Material and substantial disruption of a normal school activity means:

  • Business User means a Signing Officer, Delegate or Non-Signer.

  • Substantial Block means a number of shares of Voting Stock which have 10% or more of the aggregate voting power of all outstanding shares of Voting Stock.

  • Substantial Amount means, at the time of determination thereof, an amount in excess of 30.0% of total consolidated assets (exclusive of depreciation) at such time of the Borrower and its Subsidiaries determined on a consolidated basis.

  • commercial fishing means to take, harvest, hold, transport, or off-load marine species for sale or intended sale (R.I. Gen. Laws § 20-1-3).

  • Substantially limits means the extent to which the impairment limits an individual’s ability to perform a major life activity as compared to most people in the general population, whether or not an individual chooses to forgo mitigating measures. 42 U.S.C. 126 §12102(4); 28 CFR §35.108(d); 28 CFR §35.105(d) The rules of construction when determining whether an impairment substantially limits performance of a major life activity include:

  • Substantial means more than minor or trivial

  • Business Week means five consecutive Business Days, excluding Public Holidays as defined in the Public Holidays Act;

  • Disadvantaged Business means a small business concern: (a) which is at least 51 percent owned by one or more socially and economically disadvantaged individual(s) or in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more socially and economically disadvantaged individual(s); and (b) whose management and daily business operations are controlled by one or more of the socially and economically disadvantaged individual(s) who own it. It is important to note that the business owners themselves must control the operations of the business. Absentee ownership or title ownership by an individual who does not take an active role in controlling the business is not consistent with eligibility as a DBE under CFR 49 Part 26.71.

  • Significant means in reference to a net emissions increase or the potential of a source to emit any of the following pollutants, a rate of emissions that would equal or exceed any of the following rates:

  • windstorm means straight line winds of at least 80 miles per

  • Explosion means the sudden release of energy sufficient to cause pressure waves and/or projectiles that may cause structural and/or physical damage to the surrounding of the tested-device.

  • All Risk property insurance on a full replacement cost basis insuring CLEC’s property situated on or within any CenturyLink Premises. CLEC may elect to insure business interruption and contingent business interruption, as it is agreed that CenturyLink has no liability for loss of profit or revenues should an interruption of service occur.

  • Certificate of Substantial Performance means a certificate issued by the NCC when the Work reaches Substantial Performance;

  • COVID-19 Pandemic means the epidemic, pandemic or disease outbreak associated with COVID-19.

  • Substantial bodily injury means "bodily injury which involves (A) a temporary but substantial disfigurement; or (B) a temporary but substantial loss or impairment of the function of any bodily member, organ, or mental faculty." See 18 U.S.C. § 113(b)(1).

  • Business use means the use of a manufactured

  • Commercial cannabis activity means the production, cultivation,

  • Covered Business means (A) during the term, any business in which the Company is engaged and (B) after the Term, any business in which the Company was engaged as of the end of the Term.