Participating Provider Sample Clauses

Participating Provider. A provider who has contracted with the health plan to deliver medical/behavioral health services to covered persons. The provider may be a physician, hospital, pharmacy, other facility or other healthcare provider who has contractually accepted the terms and conditions set forth by the health plan. Also known as network or in-network provider.
Participating Provider. A state-licensed, certified or state-registered provider of health care services, treatment, or supplies, including but not limited to those entities defined in La. R.S. 40:1299.41(A)(1), that have entered into a contract or agreement with a managed care entity to provide such services, treatment, or supplies to an individual Member or a patient. Participating Provider also includes any Provider who, under contract or agreement with a health insurance issuer, such as Company and as defined in the Louisiana Insurance Code (Title 22), or with its contractor or subcontractor, has agreed to provide Covered Services to Members with an expectation of receiving payment, other than in-network Coinsurance, Copayments and/or Deductibles, directly or indirectly from Company or the health insurance issuer. La. R.S. 22:1007(A)(5); La. R.S. 22:1019.1(D)(18).
Participating Provider. A CHAMPUS- authorized provider that is required, or has agreed by entering into a CHAMPUS participation agreement or by act of indicating ‘‘accept assign- ment’’ on the claim form, to accept the CHAMPUS-allowable amount as the maximum total charge for a service or item rendered to a CHAMPUS bene- ficiary, whether the amount is paid for fully by CHAMPUS or requires cost- sharing by the CHAMPUS beneficiary. Part-time or intermittent home health aide and skilled nursing services. Part- time or intermittent means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (com- bined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-bay-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). Party to a hearing. An appealing party or parties and CHAMPUS. Party to the initial determination. In- cludes CHAMPUS and also refers to a CHAMPUS beneficiary and a partici- pating provider of services whose inter- ests have been adjudicated by the ini- tial determination. In addition, a pro- vider who has been denied approval as an authorized CHAMPUS provider is a party to that initial determination, as is a provider who is disqualified or ex- cluded as an authorized provider under CHAMPUS, unless the provider is ex- cluded based on a determination of abuse or fraudulent practices or proce- dures under another federal or xxxxx- ally funded program. See § 199.10 for ad- ditional information concerning par- ties not entitled to administrative re- view under the CHAMPUS appeals and hearing procedures.
Participating Provider. A hospital, physician, physician organization, Participating Physician Group, Member Physician, other health care practitioner or other organization which has a direct or indirect contractual relationship with FHS or another Participating Provider to provide Covered Services to Members. In the event PPG contracts with a health care provider to render Covered Services under this Agreement, such provider is a Participating Provider.
Participating Provider. A physician duly licensed to practice medicine in the State of Delaware, participating in or eligible to participate in the Delaware Medicaid program, and who is a member of the medical staff of a(n) ACDE- participating hospital, or a licensed, appropriately supervised allied health professional, either of whom has entered into, or who is recognized by ACDE as a member of a group which has entered into, an agreement with ACDE to provide medical services to Members under the Program.