Emergency Health Care Services Sample Clauses

Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Health Care Services are administered by either an In-network or Out-of-network Practitioner/Provider, benefits for the initial treatment are paid at the In-network benefit level. If you, as a result of Emergency Health Care Services, are admitted to an Out-of-network Hospital you may choose to be transferred to a Hospital that is in our Practitioner/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will apply. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person Prior Authorization is not required for Emergency Health Care Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us within 48 hours so we can review your Hospital stay. For Emergency Health Care Services outside of our Service Area, you may seek Emergency Health Care Services from the nearest appropriate facility where Emergency Health Care Services can be rendered. These services will be Covered as In-network services. Non-emergent follow-up care received from an Out-of-network Practitioner/Provider is Covered at the Out-of- network level of benefits. Observation Services Observation services are defined as Outpatient services furnished by a Hospital and Practitioner/Provider on the Hospital’s premises. These services may include the use of a bed and periodic monitoring by a Hospital’s nursing staff which are reasonable and necessary to: • Evaluate an outpatient’s condition • Determine the need for a possible admission to the Hospital • When rapid improvement of the...
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Emergency Health Care Services. 4.16.5.1 The Contractor shall not deny or inappropriately reduce payment to a provider of emergency health care services for any evaluation, diagnostic testing, or treatment provided to a recipient of medical assistance for an emergency condition; or
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Emergency Health Care Services. Benefits for treatment of Emergency medical conditions and Emergency screening and Stabilization services without Prior Authorization for conditions that reasonably appear to a prudent layperson to constitute an Emergency medical condition based upon the patient’s presenting symptoms and conditions. Benefits for Emergency Care include facility costs and Physician services, and supplies and Prescription Drugs charged by that facility. Whenever You are admitted as an Inpatient directly from a Hospital emergency room, the Emergency Room Services Copay/Coinsurance for that Emergency Room visit will be waived. For an Inpatient admission following Emergency Care, Precertification is not required. However, Your Physician or the Inpatient facility must seek authorization for your admission within 48 hours or as soon as possible within a reasonable period of time. When We are contacted, Your Provider will be notified whether the Inpatient setting is appropriate and considered Medically Necessary.If Prior Authorization is not obtained within 48 hours of your admission You may be financially responsible for Your Inpatient care. Care and treatment provided once You are Stabilized is no longer considered Emergency Care. Continuation of care from a Non-Participating Provider beyond that needed to evaluate or Stabilize Your condition in an Emergency may be Covered if We authorize the continuation of care and it is Medically Necessary. Transfer to a Participating Provider will be made available to persons receiving post-stabilization care in a Non-Participating Provider facility.
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Emergency Health Care Services. The City shall provide immediate emergency health care services to faculty and students participating in the program in the event of accidental injury or illness while on the City's premises. At the time of providing such services, the City shall accept assignment of the affected individual's insurance policy. The City shall not be responsible for costs involved in the provision of such services, the follow- up care, or hospitalization.
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Emergency Health Care Services. Care planning in relation to sudden illness should begin as part of the admission process. You acknowledge receipt of Clearview’s written policy related to the use of life-sustaining procedures, CPR and comfort measures. You authorize Clearview to obtain emergency health care services when services are required and your health care provider or alternate is unavailable.
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Emergency Health Care Services. This Agreement covers acute Emergency Health Care Services 24 hours per day, seven days per week, when those services are needed immediately to prevent jeopardy to your health. You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network (outside of the 5-county area) facility at the In-network benefit level. Whether Out-of-network (outside of the 5-county area) Emergency Health Care Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive health care procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person
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Emergency Health Care Services. (a) If we determine that the Health Care Services were not an Emergency, the Health Care Services are Non-Covered Services and you will be responsible for costs associated with the Health Care Services.
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Related to Emergency Health Care Services

  • COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

  • Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.

  • Health Care Operations Health Care Operations shall have the meaning set out in its definition at 45 C.F.R. § 164.501, as such provision is currently drafted and as it is subsequently updated, amended or revised.

  • Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.

  • Outpatient emergency and urgicenter services within the service area The emergency room copay applies to all outpatient emergency visits that do not result in hospital admission within twenty-four (24) hours. The urgicenter copay is the same as the primary care clinic office visit copay.

  • HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.

  • 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

  • Extended Health Care Plan (a) The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable Extended Health Care Plan.

  • Mental Health Services This agreement covers medically necessary services for the treatment of mental health disorders in a general or specialty hospital or outpatient facilities that are: • reviewed and approved by us; and • licensed under the laws of the State of Rhode Island or by the state in which the facility is located as a general or specialty hospital or outpatient facility. We review network and non-network programs, hospitals and inpatient facilities, and the specific services provided to decide whether a preauthorization, hospital or inpatient facility, or specific services rendered meets our program requirements, content and criteria. If our program content and criteria are not met, the services are not covered under this agreement. Our program content and criteria are defined below.

  • Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.

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