Xxxxxx Selectives Sample Clauses

Related to Xxxxxx Selectives

Value-Based Programs If you receive covered healthcare services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to us through average pricing or fee schedule adjustments. The following defined terms only apply to the BlueCard section only: • Care Coordinator Fee is a fixed amount paid by us to providers periodically for Care Coordination under a Value-Based Program. • Care Coordination is organized, information-driven patient care activities intended to facilitate the appropriate responses to an enrolled member’s healthcare needs across the continuum of care. • Value-Based Program (VBP) is an outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. • Provider Incentive is an additional amount of compensation paid to a healthcare provider by us, based on the provider’s compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to insured accounts. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside Our Service Area • Enrolled Member Liability Calculation When covered healthcare services are provided outside of BCBSRI service area by nonparticipating providers, the amount an enrolled member pays for such services will generally be based on either the Host Blue’s nonparticipating provider local payment or the pricing arrangements required by applicable law. In these situations, the enrolled member may be responsible for the difference between the amount that the nonparticipating provider bills and the payment BCBSRI will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments, including but not limited to, emergency services, air ambulance services, and certain covered healthcare services rendered by a nonparticipating provider. • Exceptions In some exception cases, BCBSRI may pay claims from nonparticipating healthcare providers outside of BCBSRI service area based on the provider’s billed charge. This may occur in situations where an enrolled member did not have reasonable access to a participating provider, as determined by BCBSRI. In other exception cases, BCBSRI may pay such claims based on the payment BCBSRI would pay to a local nonparticipating provider (as described in the above subsection “How Non-network Providers Are Paid”). This may occur where the Host Blue’s corresponding payment would be more than BCBSRI in-service area nonparticipating provider payment. BCBSRI may choose to negotiate a payment with such a provider on an exception basis. Unless otherwise stated, in any of these exception situations, the enrolled member may be responsible for the difference between the amount that the nonparticipating healthcare provider bills and payment BCBSRI will make for the covered services as set forth in this paragraph. Blue Cross Blue Shield Global® Core If you are outside the United States (hereinafter “BlueCard service area”), you may be able to take advantage of the Blue Cross Blue Shield Global Core when accessing covered healthcare services. The Blue Cross Blue Shield Global Core is unlike the BlueCard Program available in the BlueCard service area in certain ways. For instance, although the Blue Cross Blue Shield Global Core assists you with accessing a network of inpatient, outpatient and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the BlueCard service area, you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. • Inpatient Services: In most cases, if you contact the service center for assistance, hospitals will not require you to pay for covered inpatient services, except for your cost-share amounts/deductibles, coinsurance, etc. In such cases, the hospital will submit your claims to the service center to begin claims processing. However, if you paid in full at the time of service, you must submit a claim to receive reimbursement for covered healthcare services. • Outpatient Services: Physicians, urgent care centers and other outpatient providers located outside the BlueCard service area will typically require you to pay in full at the time of service. You must submit a claim to obtain reimbursement for covered healthcare services. Preauthorization may be required for outpatient services. • Submitting a Blue Cross Blue Shield Global Core Claim: When you pay for covered healthcare services outside the BlueCard service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a Blue Cross Blue Shield Global Core claim form and send the claim form with the provider’s itemized bill(s) to the service center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from BCBSRI, the service center or online at xxx.xxxxxxxxxxxxxx.xxx. If you need assistance with your claim submission, you should call the service center at 0.000.000.XXXX (2583) or call collect at 0.000.000.0000, 24 hours a day, seven days a week.
Quality- and Cost-Based Selection Except as ADB may otherwise agree, the Borrower shall apply quality- and cost-based selection for selecting and engaging consulting services.
Panel Selection 1. The Parties shall apply the following procedures in selecting a Panel: (a) the Panel shall comprise 3 members; (b) within 15 days following the date of the establishment of the Panel, each Party shall nominate a Panelist; (c) the Parties shall endeavor
Quality-based Selection Services for assignments which the Bank agrees meet the requirements set forth in paragraph 3.2 of the Consultant Guidelines may be procured under contracts awarded on the basis of Quality-based Selection in accordance with the provisions of paragraphs 3.1 through 3.4 of the Consultant Guidelines.
Multi-year Planning Targets Schedule A may reflect an allocation for the first Funding Year of this Agreement as well as planning targets for up to two additional years, consistent with the term of this Agreement. In such an event, the HSP acknowledges that if it is provided with planning targets, these targets:
Performance indicators and targets The purpose of the innovation performance indicators and targets is to assist the University and the Commonwealth in monitoring the University's progress against the Commonwealth's objectives and the University's strategies for innovation. The University will report principal performance information and aim to meet the innovation performance indicators and targets set out in the following tables.
Designated Teacher for Looked After Children 17A) The Academy Trust will in respect of the Academy act in accordance with, and be bound by, all relevant statutory and regulatory provisions and have regard to any guidance and codes of practice issued pursuant to such provisions, as they apply at any time to a maintained school, relating to the designation of a person to manage the teaching and learning programme for children who are looked after by a LA and are registered pupils at the school. For the purpose of this clause, any reference to the governing body of a maintained school in such statutory and regulatory provisions, or in any guidance and code of practice issued pursuant to such provisions, shall be deemed to be references to the Governing Body of the Academy Trust. Teachers and other staff
Committee on Technical Barriers to Trade 1. The Parties hereby establish the Committee on Technical Barriers to Trade, comprising representatives of each Party.
Selection Criteria for Awarding Task Order The Government will award to the offeror whose proposal is deemed most advantageous to the Government based upon an integrated assessment using the evaluation criteria. The Government will evaluate proposals against established selection criteria specified in the task order RFP. Generally, the Government's award decision will be based on selection criteria which addresses past performance, technical acceptability, proposal risk and cost. Among other sources, evaluation of past performance may be based on past performance assessments provided by TO Program Managers on individual task orders performed throughout the life of the contract. The order of importance for the factors will be identified in the RFP for the specified task order.
Information Technology Accessibility Standards Any information technology related products or services purchased, used or maintained through this Grant must be compatible with the principles and goals contained in the Electronic and Information Technology Accessibility Standards adopted by the Architectural and Transportation Barriers Compliance Board under Section 508 of the federal Rehabilitation Act of 1973 (29 U.S.C. §794d), as amended. The federal Electronic and Information Technology Accessibility Standards can be found at: xxxx://xxx.xxxxxx-xxxxx.xxx/508.htm.