Level of Care Re-Determinations Sample Clauses

Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTC FS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTC FS. The responsibility to assure that all members have a current and accurate level of care shall include:
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Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO shall consult with the ADRC if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollment. (The member will lose eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Level of Care Determinations and Redeterminations for Private Pay Individuals Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of “Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCO.
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Level of Care Re-Determinations. The PO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include:
Sample 1
Level of Care Re-Determinations. The PO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTC FS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTC FS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The PO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The PO shall consult with the ADRC if the PO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The PO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee if differences cannot be resolved.
Sample 1

Related to Level of Care Re-Determinations

  • Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:

  • Preventive Care and Early Detection Services This plan covers, early detection services, preventive care services, and immunizations or vaccinations in accordance with state and federal law, including the Affordable Care Act (ACA), as set forth below and in accordance with the guidelines of the following resources: • services that have an A or B rating in the current recommendations of the U.S. Preventative Services Task Force (USPSTF); • immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; • preventive care and screenings for infants, children, and adolescents as outlined in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); or • preventive care and screenings for women as outlined in the comprehensive guidelines as supported by HRSA. Covered early detection services, preventive care services and adult and pediatric immunizations or vaccinations are based on the most currently available guidelines and are subject to change. The amount you pay for preventive services will be different from the amount you pay for diagnostic procedures and non-preventive services. See the Summary of Medical Benefits and the Summary of Pharmacy Benefits for more information about the amount you pay. Preventive Office Visits This plan covers the following preventive office visits. • Annual preventive visit - one (1) routine physical examination per plan year per member age 36 months and older; • Pediatric preventive office and clinic visits from birth to 35 months - 11 visits; • Well Woman annual preventive visit - one (1) routine gynecological examination per plan year per female member.

  • Standard of Care; Performance of Employees Consultant shall perform all Services under this Agreement in a skillful and competent manner, consistent with the standards generally recognized as being employed by professionals in the same discipline in the State of California. Consultant represents and maintains that it is skilled in the professional calling necessary to perform the Services. Consultant agrees that all employees and subconsultants shall have sufficient skill and experience to perform the Services assigned to them. Finally, Consultant represents that it, its employees and subconsultants shall have all licenses, permits, qualifications and approvals of whatever nature that are legally required to perform the Services, including a City Business License, and that such licenses and approvals shall be maintained throughout the Term of this Agreement. As provided for in the indemnification provisions of this Agreement, Consultant shall perform, at its own cost and expense and without reimbursement from the City, any services necessary to correct errors or omissions which are caused by the Consultant’s failure to comply with the standard of care provided for herein. Any employee of the Consultant or its sub-consultants who is determined by the City to be uncooperative, incompetent, a threat to the adequate or timely completion of the Project, a threat to the safety of persons or property, or any employee who fails or refuses to perform the Services in a manner acceptable to the City, shall be promptly removed from the Project by the Consultant and shall not be re-employed to perform any of the Services or to work on the Project.

  • SPECIALIZED SERVICE REQUIREMENTS In the event that the Participating Entity requires service or specialized performance requirements not addressed in this Contract (such as e- commerce specifications, specialized delivery requirements, or other specifications and requirements), the Participating Entity and the Supplier may enter into a separate, standalone agreement, apart from this Contract. Sourcewell, including its agents and employees, will not be made a party to a claim for breach of such agreement.

  • Service Exclusions All of an Employee's years of Service with the Employer shall be counted to determine the vested interest of such Employee except:

  • Offense Level Calculations i. The base offense level is 7, pursuant to Guideline § 2B1.1(a)(1).

  • Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered

  • Service Levels Annex 1 to this Part A of this Contract Schedule 6 sets out the Service Levels the performance of which the Parties have agreed to measure. The Supplier shall monitor its performance of this Contract by reference to the relevant performance criteria for achieving the Service Levels shown in Annex 1 to this Part A of this Contract Schedule 6 (the “Service Level Performance Criteria”) and shall send the Customer a Performance Monitoring Report detailing the level of service which was achieved in accordance with the provisions of Part B (Performance Monitoring) of this Contract Schedule 6. The Supplier shall, at all times, provide the Goods and/or Services in such a manner that the Service Levels Performance Measures are achieved. If the level of performance of the Supplier of any element of the provision by it of the Goods and/or Services during the Contract Period: is likely to or fails to meet any Service Level Performance Measure or is likely to cause or causes a Critical Service Failure to occur, the Supplier shall immediately notify the Customer in writing and the Customer, in its absolute discretion and without prejudice to any other of its rights howsoever arising including under Clause 13 of this Contract (Service Levels and Service Credits), may: require the Supplier to immediately take all remedial action that is reasonable to mitigate the impact on the Customer and to rectify or prevent a Service Level Failure or Critical Service Level Failure from taking place or recurring; and if the action taken under paragraph (a) above has not already prevented or remedied the Service Level Failure or Critical Service Level Failure, the Customer shall be entitled to instruct the Supplier to comply with the Rectification Plan Process; or if a Service Level Failure has occurred, deduct from the Contract Charges the applicable Service Level Credits payable by the Supplier to the Customer in accordance with the calculation formula set out in Annex 1 of this Part A of this Contract Schedule 6; or if a Critical Service Level Failure has occurred, exercise its right to Compensation for Critical Service Level Failure in accordance with Clause 14 of this Contract (Critical Service Level Failure) (including subject, for the avoidance of doubt, the proviso in Clause 14.2.2 of this Contract in relation to Material Breach). Approval and implementation by the Customer of any Rectification Plan shall not relieve the Supplier of any continuing responsibility to achieve the Service Levels, or remedy any failure to do so, and no estoppels or waiver shall arise from any such Approval and/or implementation by the Customer. SERVICE CREDITS Annex 1 to this Part A of this Contract Schedule 6 sets out the formula used to calculate a Service Credit payable to the Customer as a result of a Service Level Failure in a given service period which, for the purpose of this Contract Schedule 6, shall be a recurrent period of [one Month] during the Contract Period (the “Service Period”). Annex 1 to this Part A of this Contract Schedule 6 includes details of each Service Credit available to each Service Level Performance Criterion if the applicable Service Level Performance Measure is not met by the Supplier. The Customer shall use the Performance Monitoring Reports supplied by the Supplier under Part B (Performance Monitoring) of this Contract Schedule 6 to verify the calculation and accuracy of the Service Credits, if any, applicable to each relevant Service Period. Service Credits are a reduction of the amounts payable in respect of the Goods and/or Services and do not include VAT. The Supplier shall set-off the value of any Service Credits against the appropriate invoice in accordance with calculation formula in Annex 1 of Part A of this Contract Schedule 6.

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