Provision of Covered Services. Contractor shall undertake commercially reasonable efforts to ensure that each Participating Provider Agreement and each subcontracting arrangement entered into by each Participating Provider complies with the applicable terms and conditions set forth in this Agreement, as mutually agreed upon by Covered California and Contractor, and which may include the following:
Provision of Covered Services. Medical Group and its Participating Providers shall provide Covered Services to Commercial Plan Members pursuant to the terms of the Base Agreement and this Product Attachment A.
Provision of Covered Services. Contractor shall cause each Participating Provider to assure that each Participating Provider Agreement and each subcontracting arrangement entered into by each Participating Provider shall comply with, the applicable terms and conditions set forth in the Agreement, as mutually agreed upon by the Exchange and Contractor, and which may include the following: • Coordination with the Exchange and other programs and stakeholders (Section 1.06); • Relationship of the parties as independent contractors (Section 1.08(a)) and Contractor’s exclusive responsibility for obligations under the Agreement (Section 1.08(b)); • Participating Provider directory requirements (Section 3.05(c)); • Implementation of processes to enhance stability and minimize disruption to provider network (Section 3.05(d) and (e); • Notice, network requirements and other obligations relating to costs of out-of-network and other benefits (Section 3.1); • Credentialing, including, maintenance of licensure and insurance (Section 3.16); • Customer service standards (Section 3.18); • Utilization review and appeal processes (Section 3.17); • Maintenance of a corporate compliance program (Section 3.19); • Enrollment and eligibility determinations and collection practices (Sections 3.20 to 3.25) • Appeals and grievances (Section 3.26); • Enrollee and marketing materials (Section 3.27); • Disclosure of information required by the Exchange, including, financial and clinical (Section 3.31; Quality, Network Management and Delivery System Standards (Article 4 ) and other data, books and records (Article 10)); • Nondiscrimination (Section 3.32); • Conflict of interest and integrity (Section 3.33); • Other laws (Section 3.35); • Quality, Network Management and Delivery System Standards to the extent applicable to Participating Providers (Article 4), including, disclosure of contracting arrangements with Participating Providers as required under Section 7.01 of the Quality, Network Management and Delivery System Standards; • Performance Measures, to the extent applicable to Participating Providers (Article 6) • Continuity of care, coordination and cooperation upon termination of Agreement and transition of Enrollees (Article 7); • Security and privacy requirements, including, compliance with HIPAA (Article 9); and • Maintenance of books and records (Article 10).
Provision of Covered Services. Provider may not refuse to provide Medically Necessary or preventive Covered Services to a child under the age of twenty-one (21) or other Covered Persons for non-medical reasons. Provider is not required to accept or continue treatment of a patient with whom Provider feels he or she cannot establish and/or maintain a professional relationship. Provider shall follow the applicable CRA’s requirements for the provision of Covered Services. Provider’s decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions:
Provision of Covered Services. 2.2.1 Provider agrees to provide Covered Services to Members on a twenty-four (24) hours per day, seven (7) days per week basis, except Providers who do not provide emergency services shall ensure that Covered Services are available to Covered Persons in accordance with standard operating hours for each Provider location and shall maintain an after-hours phone service for Covered Persons to seek instructions in the event of an emergency.
Provision of Covered Services. Provider shall provide Covered Services to Members, within the scope of Provider’s license, in accordance with this Agreement, Health Plan’s policies and procedures, the terms and conditions of the Health Plan product which covers the Member, and the requirements of any applicable government sponsored program.
Provision of Covered Services. Provider agrees to render Covered Services to Members eligible for coverage under Title XVIII of the Social Security Act, as amended, in accordance with the terms and conditions of the MA PPO Program and BCBSM MA PPO Program requirements. Such BCBSM MA PPO Program requirements include the provisions of BCBSM’s applicable EOC, operational policies and procedures, utilization management program and quality management program requirements with which Provider shall comply in rendering Covered Services. BCBSM shall supply Provider with the MA PPO Program requirements not set forth in this Agreement through its MA PPO Provider Manual and any amendments thereto. Determination of Covered Services shall be governed by coverage guidelines established by BCBSM and the MA PPO Program, with BCBSM being solely responsible for final coverage determination, subject to the applicable appeal procedures.
Provision of Covered Services. Participating Provider agrees to and shall participate in all Health Benefits Plans as may be required by QualCare hereunder. Participating Provider agrees to and shall provide, and arrange for the provision of, Covered Services, including without limitation Emergency services and Urgently Needed Services, as applicable, to Members pursuant to such Plans, pursuant to such Payor Agreements entered into between QualCare and the applicable Payors, pursuant to this Agreement, and pursuant to the Provider Manual, and shall comply with, and shall arrange for compliance with, all of the terms and conditions of each Payor Agreement, this Agreement, and the Provider Manual; provided, however, that the Payor Agreement, this Agreement, or the Provider Manual shall not require Participating Provider to provide services, charge of a fee, or engage in activities that would cause Participating Provider to be in violation of any applicable law, rule, or regulation. Such Covered Services shall be within the Participating Provider’s license, certification, and authorization as well as scope of service or specialty, consistent with standards prevailing in the community at the time the Covered Services are rendered.
Provision of Covered Services. PPG shall arrange Covered Services for assigned Members. For the purposes of this Addendum. “Covered Services” means those health care services, supplies and items set that are specified as being covered under the Healthy Families Agreement. PPG shall ensure that it and its Participating Providers arrange Covered Services for Members, in accordance with the following, each of which is hereby incorporated by reference as if set out in full herein:
Provision of Covered Services. You agree to provide to Covered Persons those Covered Services that Your Providers are licensed and credentialed to provide in compliance with this Agreement and an applicable Payer Agreement, and to provide such Covered Services in accordance with the same standards and in the same manner as Your other patients. You agree not to discriminate against any Covered Person based on any legally protected status, marital status, health status, or income.
