Denials A claim denial, also known as an adverse benefit determination, is any of the following: • a full or partial denial of a benefit; • a reduction of a benefit; • a termination of a benefit; • a failure to provide or make a full or partial payment for a benefit; and • a rescission of coverage, even if there is no adverse effect on any benefit. If we deny payment for a service we determine not medically necessary, a determination letter will be provided with the following information: • reason for the denial; • clinical criteria used to make the determination as well as how to obtain a copy of the clinical criteria; and • instructions for filing a medical appeal.
Claims Administration An employee will be required to comply with any and all rules and regulations and/or limitations established by the carrier or applicable third party administrator and contained in the policy, and employees and their dependents shall look solely to such carrier or third party administration for the adjudication of the payment of any and all benefits claims.
Medical Verification The Town may require medical verification of an employee’s absence if the Town perceives the employee is abusing sick leave or has used an excessive amount of sick leave. The Town may require medical verification of an employee’s absence to verify that the employee is able to return to work with or without restrictions.
Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Once a Medicaid application has been submitted on the Resident’s behalf, the Resident, Sponsor, and Resident Representative agree to pay, to the extent they have access to the Resident’s funds, to the Facility the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget. Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the determination of NAMI amounts, and it is the obligation of the Resident, Resident Representative and/or Sponsor to appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is established, the Resident, Resident Representative and/or Sponsor agree to pay NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure timely Medicaid recertification. The Resident, Sponsor and Resident Representative agree to provide to the Facility copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) they receive from the Department of Social Services related to the Resident’s Medicaid coverage. Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s authorized representative can appeal such denial; however, payment for any uncovered services will be owed to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established and retroactively covers any period for which private payment has been made, the Facility agrees to refund or credit any amount in excess of the NAMI owed during the covered period.
CONTRACTOR California Department of General Services Use Only CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.) BY (Authorized Signature) ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING ADDRESS STATE OF CALIFORNIA AGENCY NAME BY (Authorized Signature) ✍ DATE SIGNED (Do not type) PRINTED NAME AND TITLE OF PERSON SIGNING Exempt per: ADDRESS Exhibit A Project Summary & Scope of Work
Preventive Care This plan covers preventive care as described below. “
Compassionate Care Leave (a) Compassionate care leave will be granted to an employee for up to eight (8) weeks within a twenty-six (26) week period to provide care or support to a family member who is at risk of dying within that 26-week period in accordance with section 49.1 of the Employment Standards Act, 2000.
Accident Prevention Health and Safety Committee The Employer and the Union agree that they mutually desire to maintain standards of safety and health in the Hospital in order to prevent accidents, in jury and illness. its responsibilities under the applicable legislation, the agrees to accept as a member of its Accident Prevention Health 6 Safety Committee at l e a s t one representative selected or appointed by the Union from amongst bargaining unit employees. shall identify potential dangers and hazards, institute means of improving health and programs and recommend to be a e improve related and health. The Hospital agrees to co-operate i providing information to enable the Committee to its function. shall i be at the call of Chair if shall minutes O f all meetings t h e s a m e available for representative o r selected accordance with shall serve for a of one calendar year the date of appointment which may renewed for further periods of one year. off for such to attend meetings of the Accident Prevention and Safety Committee accordance with shall and spent s h a l l be deemed to b e work time for which the representative(s) shall be paid by the a t his/her regular or premium rate as m a y be applicable. ARTICLE PAID The Holidays with pay for this Agreement shall be: New's Years Day Good Friday Easter Monday Victoria Day Dominion Da) Holiday (as locally declared) During of this the Day, which is not a day, shall be granted third in If a that shall replace this holiday. t the nature of services necessary a Hospital, of the e m p l o y e e s ma be required work these In general, may required alternate with other in absent instance, an e m p l o y e e having Day off 0 be off on Year's Day. a the preference. To qualify for holiday pay as above, an employee must work his or her full regularly scheduled shift immediately preceding and his or her full regularly scheduled shift immediately succeeding the Holiday. In the event of an employee being prevented from working the shift immediately preceding and/or succeeding such holiday by reason of illness, authenticated by medical certificate or otherwise, lasting more than five full working such employee shall qualify for holiday pay, it being further understood and agreed that no employee shall receive holiday pay for more than one holiday during any one illness except for holidays over the Christmas and Year's periods, in which case no employee shall receive pay for more than three holidays. of the above named holidays an regular day off, or during his or her vacation the employee receive off payment for holidays in lieu thereof, but additional shall not be added to the period of vacation of employee except the of the Department his work shall time half time rate of o r . such in addition any entitled or at the option of the the employee may be paid time one half for the time worked and a paid day off in lieu thereof, or, (or a further option of the Hospital), the employee may be paid his regular straight time plus a paid clay and a half off in lieu thereof. Failure report for work assigned on such holiday shall disqualify employee for holiday pay.
Transportation Reimbursement Employees who, during the course of their normal duties, are required to actually transport clients/consumers/felons in their own personal vehicle on a regular basis, are eligible for reimbursement for the cost of an automobile rider to their existing insurance policy. To be eligible for the reimbursement, the employee must demonstrate the following:
Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s
