Eligibility Determinations. Provider or Contracted Provider shall timely verify whether an individual seeking Covered Services is a Covered Person. Company or Payor, as applicable, will make available to Provider and Contracted Providers a method, whereby Provider and Contracted Providers can obtain, in a timely manner, general information about eligibility and coverage. Company or Payor, as applicable, does not guarantee that persons identified as Covered Persons are eligible for benefits or that all services or supplies are Covered Services. If Company, Payor or its delegate determines that an individual was not a Covered Person at the time services were rendered, such services shall not be eligible for payment under this Agreement. In addition, Company will use reasonable efforts to include or contractually require Payors to clearly display Company’s name, logo or mailing address (or other identifier(s) designated from time to time by Company) on each membership card.
Eligibility Determinations. The Division will be responsible for confirming the eligibility of Enrollees for enrollment in the Plan. The Division will re-determine eligibility annually and will provide the Contractor with information relative to each Enrollee's continued eligibility for enrollment.
Eligibility Determinations. (1) General rules regarding eligibility determinations (a) Upon completing the administration of tests and other evaluation materials, a group of qualified professionals and the parent of the child must determine whether the child is a child with a disability, as defined in 34 CFR Sec. 300.8 and Paragraph (2) of Subsection B of 6.31.2.7
Eligibility Determinations. It shall be the sole responsibility of the Department to determine the criteria for the initial and continuing eligibility of clients for the services provided under this agreement; provided, however that the Vendor, for cause shown and subject to the HEARING & GRIEVANCE PROCEDURES set forth below, many deny further service to any eligible person.
Eligibility Determinations. ABD Related. Eligibility determinations for ABD related populations in the community must follow the income and resource methodologies of the SSI program and the current Medicaid state plan.
Eligibility Determinations. CMS and RI EOHHS shall have sole responsibility for determining the eligibility of an Eligible Beneficiary for Medicare- and Medicaid-funded services. CMS and RI EOHHS shall have sole responsibility for determining Enrollment in the Contractor’s MMP.
Eligibility Determinations. Upon request for services under this Agreement by an Employer, the Employer shall immediately notify Xxxxx Health Plans using the applicable form of all persons entitled to continuation coverage under applicable law, including in its notification information with respect to persons currently continuing coverage under the Plan to allow Xxxxx Health Plans to assume responsibility for the future administration of the continuation of said coverage. To the extent that the Employer fails to provide accurate information concerning or to notify Xxxxx Health Plans using the applicable form of the existence of persons currently continuing coverage or of new Qualified Beneficiaries, or in the event that the Employer does not provide adequate notification, Xxxxx Health Plans shall not be responsible for the failure by the Employer to notify Xxxxx Health Plans.
Eligibility Determinations. If any load is determined to contain material that does not conform to the definition of eligible debris, the load will be ordered to be deposited at another landfill or receiving facility and no payment will be allowed for that load and the Contractor will not invoice the City for such loads.
Eligibility Determinations. Carrier acknowledges and agrees that the MHBE, directly or through permissible contracting arrangements, shall make eligibility determinations, in accordance with applicable State and federal law, including but not limited to 45 CFR Parts 155, 156 and 157; §1311 of the Affordable Care Act; the Maryland Health Benefit Exchange Act; and COMAR 14.35.07, as well as the Carrier Reference Manual.
Eligibility Determinations. Company shall have the right to recover payments made to Provider if the payments are for services provided to an individual who is later determined to have been ineligible based upon information that is not available to Company at the time the service is rendered or authorization is provided. Company reserves the right to recoup any overpayment or payment made in error (e.g., a duplicate payment or payment for services rendered by Provider to a patient who was not a Member and amounts identified through routine investigative reviews of records or audits) against any other monies due to Provider under this Agreement. Moreover, Provider will return any overpayments to the extent required by Section 6402(a) of the Patient Protection and Affordable Care Act.
