Special Needs Unit Clause Samples

Special Needs Unit. A special dedicated unit within the PH-MCO and the EAP broker’s organizational structure established to deal with issues related to Members with Special Needs. Start Date — The first date on which the PH-MCO is operationally responsible and financially liable for the provision of Medically Necessary services to Members. Step Therapy — A type of Prior Authorization requirement, sometimes referred to as a fail first requirement, intended as a cost savings that begins drug therapy with the most cost-effective drug therapy, and progresses to other more costly therapies determined to be Medically Necessary. Stop-Loss Protection — Coverage designed to limit the amount of financial loss experienced by a Health Care Provider. Subcapitation — A fixed per capita amount that is paid by the PH-MCO to a Network Provider for each Member identified as being in their capitation group, whether or not the Member received medical services. Subcontract — A contract between the PH-MCO and an individual, business, university, governmental entity, or nonprofit organization to perform part or all of the PH-MCO’s responsibilities under this Agreement. Exempt from this definition are salaried employees, utility agreements and Provider Agreements, which are not considered Subcontracts for the purpose of this Agreement and, unless otherwise specified herein, are not subject to the provisions governing Subcontracts.. Subcontractor — An individual or entity that has a contract a PH-MCO that relates directly or indirectly to the performance of the PH-MCO’s obligation under its contract with the Department. A network provider is not a Subcontractor by virtue of the network Provider Agreement with the MCO, PIHP, or PAHP. Sustained Improvement — Improvement in performance documented through continued measurement of quality indicators after the performance project, study, or quality initiative is complete. Substantial Financial Risk — Financial risk set at greater than twenty-five percent (25%) of potential payments for covered services, regardless of the frequency of assessment (i.e., collection) or distribution of payments. The term