Access to Care. All Covered Services must be available to Members on a timely basis in accordance with medically appropriate guidelines, and consistent with generally accepted practice parameters, requirements in this Contract. The HMO must comply with the access requirements as established by the Texas Department of Insurance (TDI) for all HMOs doing business in Texas, except as otherwise required by this Contract. Medicaid HMOs must be responsive to the possibility of increased Members due to the phase-out of the PCCM model in Service Areas where adequate HMO coverage exists. The HMO must provide coverage for Emergency Services to Members 24 hours a day and 7 days a week, without regard to prior authorization or the Emergency Service provider’s contractual relationship with the HMO. The HMO’s policy and procedures, Covered Services, claims adjudication methodology, and reimbursement performance for Emergency Services must comply with all applicable state and federal laws and regulations, whether the provider is in-network or Out-of-Network. A HMO is not responsible for payment for unauthorized non-emergency services provided to a Member by Out-of-Network providers. The HMO must also have an emergency and crisis Behavioral Health Services Hotline available 24 hours a day, 7 days a week, toll-free throughout the Service Area. The Behavioral Health Services Hotline must meet the requirements described in Section 8.1.15. For Medicaid Members, a HMO must provide coverage for Emergency Services in compliance with 42 C.F.R. §438.114, and as described in more detail in Section 8.2.2.1. The HMO may arrange Emergency Services and crisis Behavioral Health Services through mobile crisis teams. For CHIP Members, Emergency Services, including emergency Behavioral Health Services, must be provided in accordance with the Texas Insurance Code and TDI regulations. For the CHIP Perinatal Program, refer to Attachment B-2.2 for description of emergency services for CHIP Perinates and CHIP Perinate Newborns. For the STAR, STAR+PLUS, and CHIP Programs, and for CHIP Perinate Newborns, HMO must require, and make best efforts to ensure, that PCPs are accessible to Members 24 hours a day, 7 days a week and that its Network Primary Care Providers (PCPs) have after-hours telephone availability that is consistent with, Section 8.1.4. CHIP Perinatal HMOs are not required to establish PCP Networks for CHIP Perinates. The HMO must provide that if Medically Necessary Covered Services are not available t...
Access to Care. All Covered Services must be available to Members on a timely basis in accordance the Contract's requirements and medically appropriate guidelines, and consistent with generally accepted practice parameters. The MCO must comply with the access requirements as established by the Texas Department of Insurance (TDI) for all MCOs doing business in Texas, except as otherwise required by this Contract. Medicaid MCOs must be responsive to the possibility of increased Members due to the phase-out of the PCCM model in Service Areas where HHSC has determined that adequate MCO coverage exists. The MCO must provide coverage for Emergency Services to Members 24 hours a day and seven (7) days a week, without regard to prior authorization or the Emergency Service provider's contractual relationship with the MCO. The MCO's policy and procedures, Covered Services, claims adjudication methodology, and reimbursement performance for Emergency Services must comply with all applicable state and federal laws and regulations, whether the provider is Network or Out-of-Network. A MCO is not responsible for payment for unauthorized non-emergency services provided to a Member by Out-of-Network providers.
Access to Care. PROVIDER shall:
Access to Care. Contractor shall provide culturally and linguistically appropriate services and supports, in locations as geographically close as possible, to where Members reside or seek services and choice of Providers (including physical health, behavioral health, including mental health and Substance Use Disorders, and oral health) within the delivery system network that are, if available, offered in non-traditional settings that are accessible to Families, diverse communities, and underserved populations.
Access to Care. The Contractor shall:
Access to Care. Inmates have access to care to meet their serious medical, dental, and mental health needs. Outcome: Inmates have access to care in a timely manner with referral to an appropriate clinician as needed. Measure: Documentation by DC4-698B, DC4-698A, and the Call Out Schedule (OBIS). Standard: Achievement of outcome must meet one hundred percent (100%) of chart reviews. Reference: Procedure 403.006, HSB 15.05.20 and HSB 15.03.22.
Access to Care. Primary Care Physician (PCP) In order to obtain benefits, you must designate a network PCP for each member. If you do not select a network PCP for each member, one will be assigned. You may select any network PCP who is accepting new patients from any of the following provider types:
Access to Care. To what extent are enrollees able to receive timely access to personal, home care and other services such as dental care, optometry and audiology?
Access to Care. Primary Care Provider In order to obtain benefits, you must designate a network primary care provider for each member. You may select any network primary care provider who is accepting new patients. However, you may not change your selection more frequently than once each month. If you do not select a network primary care provider for each member, one will be assigned. You may obtain a list of network primary care providers at our website or by contacting our Member Services department. Your network primary care provider will be responsible for coordinating all covered health services with other network providers. You do not need a referral from your network primary care provider for mental or behavioral health services, obstetrical or gynecological treatment and may seek care directly from a network obstetrician or gynecologist. You may change your network primary care provider by submitting a written request, online at our website, or by contacting our office at the number shown on your identification card. The change to your network primary care provider of record will be effective no later than 30 days from the date we receive your request. Network Availability Your network is subject to change upon advance written notice. A network service area may not be available in all areas. If you move to an area where we are not offering access to a network, the network provisions of the contract will no longer apply. In that event, benefits will be calculated based on the eligible service expense, subject to the deductible amount for network providers. You will be notified of any increase in premium.
Access to Care. Xxxxxx Lakeside at Reeds Landing Residents have priority access to the Xxxxxx Lakeside at Reeds Landing Health Center.
