Medically Frail Determination Sample Clauses

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows:  150 debit points for indicated medical conditions; EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK  150 debit points for combined indicated medical, behavioral health and substance abuse conditions;  75 debit points for indicated behavioral health conditions;  75 debit points for indicated substance abuse conditions; or  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the...
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Related to Medically Frail Determination

  • 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:

  • Independence from Material Breach Determination Except as set forth in Section X.D.1.c, these provisions for payment of Stipulated Penalties shall not affect or otherwise set a standard for OIG’s decision that CHSI has materially breached this CIA, which decision shall be made at OIG’s discretion and shall be governed by the provisions in Section X.D, below.

  • Final Determination His/her determination is final unless, within ten (10) days after notification, a recognized employee organization requests in writing to meet and confer thereon.

  • Challenge to Good Faith Determination Whenever the Board of Directors of the Company shall be required to make a determination in good faith of the fair value of any item under this Section 4, such determination may be challenged in good faith by the Holder, and any dispute shall be resolved by an investment banking firm of recognized national standing selected by the Holder and reasonably acceptable to the Company.

  • Good Faith Determination The Company shall from time to time make the good faith determination whether or not it is practicable for the Company to obtain and maintain a policy or policies of insurance with reputable insurance companies providing the officers and directors of the Company with coverage for losses incurred in connection with their services to the Company or to ensure the Company’s performance of its indemnification obligations under this Agreement.

  • Committee Determination Any adjustments or other action pursuant to this Section 4 shall be made by the Committee, and the Committee's determination as to what adjustments shall be made or actions taken, and the extent thereof, shall be final and binding.

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to an ICT technical, financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the President of the British Computer Society (or any other association that has replaced the British Computer Society). The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure by either Party to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his/her appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • INDEPENDENT PRICE DETERMINATION 6.1 By signing and submitting this bid, the Bidder certifies that the prices in this bid have been arrived at independently, without consultation, communication or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor; unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the Bidder prior to bid opening directly or indirectly to any other Bidder or to any competitor; no attempt has been made, or will be made, by the Bidder to induce any person or firm to submit, or not to submit, a bid for the purpose of restricting competition.

  • Eligibility Determination The State or its designee will make eligibility determinations for each of the HHSC HMO Programs.

  • Determination of Excise Tax Liability Unless the Company and the Executive otherwise agree in writing, the Company will select a professional services firm (the “Firm”) to make all determinations required under this Section 6, which determinations will be conclusive and binding upon the Executive and the Company for all purposes. For purposes of making the calculations required by this Section 6, the Firm may make reasonable assumptions and approximations concerning applicable taxes and may rely on reasonable, good faith interpretations concerning the application of Sections 280G and 4999 of the Code. The Company and the Executive will furnish to the Firm such information and documents as the Firm reasonably may request in order to make determinations under this Section 6. The Company will bear the costs and make all payments for the Firm’s services in connection with any calculations contemplated by this Section 6. The Company will have no liability to the Executive for the determinations of the Firm.

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