Coverage and Authorization of Services Clause Samples

The "Coverage and Authorization of Services" clause defines which services are included under an agreement and outlines the process for obtaining approval before those services are provided. Typically, this clause specifies the types of services that are eligible for coverage, any limitations or exclusions, and the steps required to secure authorization, such as submitting requests or obtaining pre-approval from a designated party. Its core practical function is to ensure that only approved and covered services are delivered and reimbursed, thereby controlling costs and preventing misunderstandings about what is included under the agreement.
Coverage and Authorization of Services. CONTRACTOR shall have in place, and follow, written authorization policies and procedures that align with the Placer County SUD authorization policy and procedure. DMC CONTRACTOR shall provide medically necessary services covered by this Agreement in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to individuals under FFS Medicaid, as set forth in 42 CFR §440.230, and for individuals under the age of 21, as set forth in 42 CFR Section 440, subpart B.
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Coverage and Authorization of Services. (42 CFR §438.210). i. The Contractor shall furnish medically necessary services covered by this Agreement in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid, as set forth in 42 CFR §440.230, and for beneficiaries under the age of 21, as set forth in 42 CFR ii. The Contractor: a. Shall ensure that the medically necessary services provided are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished. b. Shall not arbitrarily deny or reduce the amount, duration, or scope of a medically necessary service solely because of diagnosis, type of illness, or condition of the beneficiary. iii. The Contractor may place appropriate limits on a service based on criteria applied under the State Plan, such as medical necessity. iv. The Contractor may place appropriate limits on a service for the purpose of utilization control, provided that: a. The services furnished can reasonably achieve their purpose. b. The services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the enrollee’s ongoing need for such services and supports.
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Coverage and Authorization of Services. (42 CFR §438.210).
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Coverage and Authorization of Services. (42 CFR §438.210). i. The Contractor shall furnish medically necessary services covered by this Agreement in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under FFS Medicaid, as set forth in 42 CFR §440.230, and for beneficiaries under the age of 21, as set forth in 42 CFR a. Shall ensure that the medically necessary services provided are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished. b. Shall not arbitrarily deny or reduce the amount, duration, or scope of a medically necessary service solely because of diagnosis, type of illness, or condition of the beneficiary.
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Coverage and Authorization of Services. Provider selection;
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Coverage and Authorization of Services. The CONTRACTOR shall do the following:
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Coverage and Authorization of Services. (42 CFR 438.210) a. PAHPs are required to authorize and furnish MI Choice services in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to beneficiaries under Medicaid Fee for Service programs and options. b. The PAHP: i. Must ensure the services are sufficient in amount, duration, or scope to reasonably achieve the purpose for which the services are furnished. ii. May not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the participant. iii. May place appropriate limits on a service on the basis of medical necessity or for the iv. And its subcontractors have in place, and follow, written policies and procedures for the authorization of services. v. Must have mechanisms to ensure consistent application of review criteria for authorization decisions. vi. Must consult with the requesting provider for medical services when appropriate. vii. Must authorize LTSS based on an enrollee's current needs assessment and consistent with the person-centered service plan. viii. Must use individuals with appropriate expertise in addressing the participant’s medical, behavioral health or LTSS needs to make decisions to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested.
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Related to Coverage and Authorization of Services

  • Due Organization and Authorization Borrower and each Subsidiary is duly existing and in good standing in its state of formation and qualified and licensed to do business in, and in good standing in, any state in which the conduct of its business or its ownership of property requires that it be qualified except where the failure to do so could not reasonably be expected to cause a Material Adverse Change. In connection with this Agreement, the Borrower delivered to the Bank a certificate signed by the Borrower and entitled "Perfection Certificate". The Borrower represents and warrants to the Bank that: (a) the Borrower's exact legal name is that indicated on the Perfection Certificate and on the signature page hereof; and (b) the Borrower is an organization of the type, and is organized in the jurisdiction, set forth in the Perfection Certificate; and (c) the Perfection Certificate accurately sets forth the Borrower's organizational identification number or accurately states that the Borrower has none; and (d) the Perfection Certificate accurately sets forth the Borrower's place of business, or, if more than one, its chief executive office as well as the Borrower's mailing address if different, and (e) all other information set forth on the Perfection Certificate pertaining to the Borrower is accurate and complete. If the Borrower does not now have an organizational identification number, but later obtains one, Borrower shall forthwith notify the Bank of such organizational identification number. The execution, delivery and performance of the Loan Documents have been duly authorized, and do not conflict with Borrower's organizational documents, nor constitute an event of default under any material agreement by which Borrower is bound. Borrower is not in default under any agreement to which or by which it is bound in which the default could reasonably be expected to cause a Material Adverse Change.

  • Licenses and Authorizations All rights associated with the licenses, licensing agreements, permits, easements, registrations, domains, IP addresses and authorizations issued or granted to Seller by any governmental authority with respect to the operation of the Business, including, without limitation, those licenses and authorizations listed on Schedule 1.1(d) attached hereto, and all applications therefor, together with any renewals, extensions, or modifications thereof and additions thereto;

  • RESERVATION AND AUTHORIZATION OF COMMON STOCK From and after the Closing Date, the Company shall at all times reserve and keep available for issue upon the exercise of Warrants such number of its authorized but unissued shares of Common Stock as will be sufficient to permit the exercise in full of all outstanding Warrants. All shares of Common Stock which shall be so issuable, when issued upon exercise of any Warrant and payment therefor in accordance with the terms of such Warrant, shall be duly and validly issued and fully paid and nonassessable, and not subject to preemptive rights. Before taking any action which would cause an adjustment reducing the Current Warrant Price below the then par value, if any, of the shares of Common Stock issuable upon exercise of the Warrants, the Company shall take any corporate action which may be necessary in order that the Company may validly and legally issue fully paid and non-assessable shares of such Common Stock at such adjusted Current Warrant Price. Before taking any action which would result in an adjustment in the number of shares of Common Stock for which this Warrant is exercisable or in the Current Warrant Price, the Company shall obtain all such authorizations or exemptions thereof, or consents thereto, as may be necessary from any public regulatory body or bodies having jurisdiction thereof.

  • Organization and Authorization The Investor is duly incorporated or organized and validly existing in the jurisdiction of its incorporation or organization and has all requisite power and authority to purchase and hold the securities issuable hereunder. The decision to invest and the execution and delivery of this Agreement by such Investor, the performance by such Investor of its obligations hereunder and the consummation by such Investor of the transactions contemplated hereby have been duly authorized and requires no other proceedings on the part of the Investor. The undersigned has the right, power and authority to execute and deliver this Agreement and all other instruments (including, without limitations, the Registration Rights Agreement), on behalf of the Investor. This Agreement has been duly executed and delivered by the Investor and, assuming the execution and delivery hereof and acceptance thereof by the Company, will constitute the legal, valid and binding obligations of the Investor, enforceable against the Investor in accordance with its terms.

  • Power and Authority; Due Authorization The Servicer has all necessary power and authority to (i) execute and deliver this Agreement and the other Transaction Documents to which it is a party and (ii) perform its obligations under this Agreement and the other Transaction Documents to which it is a party and the execution, delivery and performance of, and the consummation of the transactions provided for in, this Agreement and the other Transaction Documents to which it is a party have been duly authorized by the Servicer by all necessary action.