Your Guide to Selecting a Primary Care Provider (PCP) and Other Providers Quality healthcare begins with a partnership between you and your primary care provider (PCP). When you need care, call your PCP, who will help coordinate your care. Your healthcare coverage under this plan is provided or arranged through our network of PCPs, specialists, and other providers. You’re encouraged to: • become involved in your healthcare by asking providers about all treatment plans available and their costs; • take advantage of the preventive health services offered under this plan to help you stay healthy and find problems before they become serious. Each member is required to provide the name of his or her PCP. However, if the name of a PCP is not provided with the application, your enrollment will not be delayed and your coverage will not be cancelled. How to Find a PCP or Other Providers Finding a PCP in our network is easy. To select a provider, or to check that a provider is in our network, please use the “Find a Doctor” tool on our website or call Customer Service. Please note: We are not obligated to provide you with a provider. We are not liable for anything your provider does or does not do. We are not a healthcare provider and do not practice medicine, dentistry, furnish health care, or make medical judgments.
Restricted Use By Outsourcers / Facilities Management, Service Bureaus or Other Third Parties Outsourcers, facilities management or service bureaus retained by Licensee shall have the right to use the Product to maintain Licensee’s business operations, including data processing, for the time period that they are engaged in such activities, provided that: 1) Licensee gives notice to Contractor of such party, site of intended use of the Product, and means of access; and 2) such party has executed, or agrees to execute, the Product manufacturer’s standard nondisclosure or restricted use agreement which executed agreement shall be accepted by the Contractor (“Non-Disclosure Agreement”); and 3) if such party is engaged in the business of facility management, outsourcing, service bureau or other services, such third party will maintain a logical or physical partition within its computer system so as to restrict use and access to the program to that portion solely dedicated to beneficial use for Licensee. In no event shall Licensee assume any liability for third party’s compliance with the terms of the Non-Disclosure Agreement, nor shall the Non-Disclosure Agreement create or impose any liabilities on the State or Licensee. Any third party with whom a Licensee has a relationship for a state function or business operation, shall have the temporary right to use Product (e.g., JAVA Applets), provided that such use shall be limited to the time period during which the third party is using the Product for the function or business activity.
Ancillary and Travel Expenses A. Except as otherwise provided in the Grant Agreement, no ancillary expenses incurred by the Grantee in connection with its provision of the services or deliverables will be reimbursed by the System Agency. Ancillary expenses include, but are not limited to, costs associated with transportation, delivery, and insurance for each deliverable.
Network Elements and Other Services Manual Additive 2.13.5.1 The Commissions in some states have ordered per-element manual additive non- recurring charges (NRC) for Network Elements and Other Services ordered by means other than one of the interactive interfaces. These ordered Network Elements and Other Services manual additive NRCs will apply in these states, rather than the charge per LSR. The per-element charges are listed on the Rate Tables in Exhibit C.
Services Available or Provided from Other Sources Services for any condition, illness, or disease which should be covered by the United States government or any of its agencies, Medicare, any state or municipal government or any of its agencies except emergency care when there is a legal responsibility to provide it. • Services or supplies for military-related conditions, such as war, or any military action, which takes place after your coverage becomes effective. • Services received in a facility mainly meant to care for students, faculty, or employees of a college or other institution of learning. • Covered healthcare services provided to you when there is no charge to you or there would have been no charge to you absent this health plan. • Services if another entity or agency is responsible under state or federal laws, which are provided for the health of schoolchildren or children with disabilities. See Title 16, Chapters 21, 24, 25, and 26 of the R.I. General Laws. See also applicable regulations about the health of schoolchildren and the special education of children with disabilities or similar rules set forth by federal law or state law of applicable jurisdiction. • Services and supplies which are required under the laws of a state, other than Rhode Island, and are not provided under this health plan. All Other Exclusions • Services not approved by the FDA or other governing body. • Services we have not reviewed or we have not determined are eligible for coverage. • Services obtained through fraud or intentional misrepresentation. • Administrative service charges for: o missed appointments; o completion of claim forms; o additional fees, sometimes referred to as access fees, associated with concierge, boutique, or retainer practices; and o any other administrative charges. • Blood services for drawing, processing, or storage of your own blood, including any penalty fees related to blood services. • Continuation of a covered healthcare service or benefit as a result of a clerical error. • Custodial care, rest care, day care, or non-skilled care services. • Convalescent homes, nursing homes including non-skilled care, assisted living facilities, or other residential facilities. • Educational classes, unless listed as covered, and training services. • Exams or services that are required for or related to employment, education, marriage, adoption, insurance purposes, court order, or similar third parties when not medically necessary or when the benefit limit for the exam or service has been met. • Routine foot care, including the treatment of corns, bunions except capsular or bone surgery, calluses, the trimming of nails, the treatment of simple ingrown nails and other preventive hygienic procedures, except when performed to treat diabetic related nerve and circulation disorders of the feet. • Treatment of flat feet unless the treatment is a covered surgical service. • Telephone consultations, telephone services, or medication monitoring by phone, except for clinically appropriate telemedicine services as described in Section 3. • Healthcare services for work-related illnesses or injuries for which benefits are available under Workers’ Compensation , whether or not you are entitled to such benefits, unless: o you are self-employed, a sole stockholder of a corporation, or a member of a partnership; and o your illnesses or injuries were incurred in the course of your self-employment, sole stockholder, or partnership activities; and o you are not enrolled as an employee under a group health plan sponsored by another employer. • Services and supplies used for your personal appearance and/or comfort, whether or not prescribed by a physician and regardless of your condition. These services and supplies include, but are not limited to: o batteries, unless indicated as covered;
Consultant’s Contract Manager and Other Staffing Identified below are the following:
Participating Providers To find out if a Provider is a Participating Provider: • Check Our Provider directory, available at Your request; • Call the number on Your ID card; or • Visit our website at xxx.xxxxxx.xxx. The Provider directory will give You the following information about Our Participating Providers: • Name, address, and telephone number; • Specialty; • Board certification (if applicable); • Languages spoken; and • Whether the Participating Provider is accepting new patients.
Excluded Providers 6.4.1 Definition of Excluded Providers In accordance with 42 CFR 438.214(d), the Contractor may not employ or contract with Providers who are Excluded from participation in Federal Health Care Programs under either Section 1128 or 1128(A) of the Social Security Act.
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
Life-Giving Procedures When approved, employees will receive paid leave, not to exceed five (5) working days in a two (2) year period, for participating in life-giving procedures. “
