Common use of Children in Substitute Care Clause in Contracts

Children in Substitute Care. Children who have been adjudicated dependent or delinquent and who are in the legal custody of a public agency and/or under the jurisdiction of the juvenile court and are living outside their homes, in any of the following settings: shelter homes, xxxxxx homes, group homes, supervised independent living, and Residential Treatment Facilities for Children (RTFs). Claim — A xxxx from a Provider of a medical service or product that is assigned a unique identifier (i.e. Claim reference number). A Claim does not include an Encounter form for which no payment is made or only a nominal payment is made. Clean Claim — A Claim that can be processed without obtaining additional information from the Provider of the service or from a third party. A Clean Claim includes a Claim with errors originating in the PH-MCO’s Claims system. Claims under investigation for Fraud or Abuse or under review to determine if they are Medically Necessary are not Clean Claims. Client Information System (CIS) — The Department's database of Recipients. The data base contains demographic and eligibility information for all Recipients. Community Provider — Private and public service organizations, that are not part of the PH-MCO’s Provider Network, with which the PH-MCO coordinates Out-of-Plan Services for their Members. Complaint — A dispute or objection regarding a participating Health Care Provider or the coverage, operations, or management policies of a Physical Health Managed Care Organization (PH-MCO), which has not been resolved by the PH-MCO and has been filed with the PH-MCO or with the Department of Health or the Pennsylvania Insurance Department of the Commonwealth, including but not limited to:  a denial because the requested service/item is not a covered benefit; or  a failure of the PH-MCO to meet the required time frames for providing a service/item; or  a failure of the PH-MCO to decide a Complaint or Grievance within the specified time frames; or  a denial of payment by the PH-MCO after a service has been delivered because the service/item was provided without authorization by a Provider not enrolled in the Pennsylvania Medical Assistance Program; or  a denial of payment by the PH-MCO after a service has been delivered because the service/item provided is not a covered service/item for the Member. The term does not include a Grievance. Concurrent Review — A review conducted by the PH-MCO during a course of treatment to determine whether the amount, duration and scope of the prescribed services continue to be Medically Necessary or whether any service, a different service or lesser level of service is Medically Necessary. County Assistance Office (CAO) — The county offices of the Department that administer all benefit programs, including MA, on the local level. Department staff in these offices perform necessary functions such as determining and maintaining Recipient eligibility.

Children in Substitute Care. Children who have been adjudicated dependent or delinquent and who are in the legal custody of a public agency and/or under the jurisdiction of the juvenile court and are living outside their homes, in any of the following settings: shelter homes, xxxxxx homes, group homes, supervised independent living, and Residential Treatment Facilities for Children (RTFs). Claim — A xxxx bill from a Provider of a medical service or product that is assigned a unique identifier (i.e. Claim reference number). A Claim does not include an Encounter form for which no payment is made or only a nominal payment is made. Clean Claim — A Claim that can be processed without obtaining additional information from the Provider of the service or from a third party. A Clean Claim includes a Claim with errors originating in the PH-MCO’s Claims system. Claims under investigation for Fraud or Abuse or under review to determine if they are Medically Necessary are not Clean Claims. Client Information System (CIS) — The Department's database of Recipients. The data base contains demographic and eligibility information for all Recipients. Community Provider — Private and public service organizations, that are not part of the PH-MCO’s Provider Network, with which the PH-MCO coordinates Out-of-Plan Services for their Members. Complaint — A dispute or objection regarding a participating Health Care Provider or the coverage, operations, or management policies of a Physical Health Managed Care Organization (PH-MCO), which has not been resolved by the PH-MCO and has been filed with the PH-MCO or with the Department of Health or the Pennsylvania Insurance Department of the Commonwealth, including but not limited to:  ▪ a denial because the requested service/item is not a covered benefit; or  ▪ a failure of the PH-MCO to meet the required time frames for providing a service/item; or  ▪ a failure of the PH-MCO to decide a Complaint or Grievance within the specified time frames; or  ▪ a denial of payment by the PH-MCO after a service has been delivered because the service/item was provided without authorization by a Provider not enrolled in the Pennsylvania Medical Assistance Program; or  ▪ a denial of payment by the PH-MCO after a service has been delivered because the service/item provided is not a covered service/item for the Member. The term does not include a Grievance. Concurrent Review — A review conducted by the PH-MCO during a course of treatment to determine whether the amount, duration and scope of the prescribed services continue to be Medically Necessary or whether any service, a different service or lesser level of service is Medically Necessary. County Assistance Office (CAO) — The county offices of the Department that administer all benefit programs, including MA, on the local level. Department staff in these offices perform necessary functions such as determining and maintaining Recipient eligibility.. Covered Outpatient Drug -- In accordance with 42 U.S.C.A. 1396r-8(k)(2) and 55 PA code Chapter 1121, the term means a brand name drug, a generic drug, or an over-the-counter drug (OTC) which:

Children in Substitute Care. Children who have been adjudicated dependent or delinquent and who are in the legal custody of a public agency and/or under the jurisdiction of the juvenile court and are living outside their homes, in any of the following settings: shelter homes, xxxxxx homes, group homes, supervised independent living, and Residential Treatment Facilities for Children (RTFs). Claim — A xxxx from a Provider of a medical service or product that is assigned a unique identifier (i.e. Claim reference number). A Claim does not include an Encounter form for which no payment is made or only a nominal payment is made. Clean Claim — A Claim that can be processed without obtaining additional information from the Provider of the service or from a third party. A Clean Claim includes a Claim with errors originating in the PH-MCO’s Claims system. Claims under investigation for Fraud or Abuse or under review to determine if they are Medically Necessary are not Clean Claims. Client Information System (CIS) — The Department's database of Recipients. The data base contains demographic and eligibility information for all Recipients. Community Provider — Private and public service organizations, that are not part of the PH-MCO’s Provider Network, with which the PH-MCO coordinates Out-of-Plan Services for their Members. Complaint — A dispute or objection regarding a participating Health Care Provider or the coverage, operations, or management policies of a Physical Health Managed Care Organization (PH-MCO), which has not been resolved by the PH-MCO and has been filed with the PH-MCO or with the Department of Health or the Pennsylvania Insurance Department of the Commonwealth, including but not limited to:  a denial because the requested service/item is not a covered benefit; or  a failure of the PH-MCO to meet the required time frames for providing a service/item; or  a failure of the PH-MCO to decide a Complaint or Grievance within the specified time frames; or  a denial of payment by the PH-MCO after a service has been delivered because the service/item was provided without authorization by a Provider not enrolled in the Pennsylvania Medical Assistance Program; or  a denial of payment by the PH-MCO after a service has been delivered because the service/item provided is not a covered service/item for the Member. The term does not include a Grievance. Concurrent Review — A review conducted by the PH-MCO during a course of treatment to determine whether the amount, duration and scope of the prescribed services continue to be Medically Necessary or whether any service, a different service or lesser level of service is Medically Necessary. County Assistance Office (CAO) — The county offices of the Department that administer all benefit programs, including MA, on the local level. Department staff in these offices perform necessary functions such as determining and maintaining Recipient eligibility.. Covered Outpatient Drug -- In accordance with 42 U.S.C.A. 1396r-8(k)(2) and 55 PA code Chapter 1121, the term means a brand name drug, a generic drug, or an over-the-counter drug (OTC) which: