Medical Group Provider definition

Medical Group Provider means an individual physician or Provider appropriately licensed to provide health care services who participates in Medical Group and includes, without limiting the foregoing, Medical Group Primary Care Physician, Medical Group Specialist, and Medical Group obstetrician/gynecologist. Medically Necessary or Medical Necessity means health care services that a Medical Group or Medical Group Provider, exercising prudent clinical judgment, would provide to a Subscriber for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Subscriber’s illness, injury or disease; and (c) not primarily for the convenience of the Subscriber, Medical Group or Medical Group Provider, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that Subscriber’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors.
View Source

Examples of Medical Group Provider in a sentence

  • Online visits are an online medical interview followed by a response from a Presbyterian Medical Group Provider.

  • Medical Group shall notify BCBSTX at least thirty (30) days in advance if there is a change in the business address, telephone number, hours of operation, tax identification number, other billing information or services provided by Medical Group or Medical Group Provider.

  • Medical Group Provider shall request Subscriber to present Subscriber’s BCBSTX identification card each time Subscriber seeks Covered Services.

  • Medical Group further acknowledges and agrees, except as may be required by Applicable Laws, a Medical Group Provider will not become a Participating Provider in BCBSTX until approved by BCBSTX pursuant to such credentialing policies and procedures and that continued participation in BCBSTX is subject to the recredentialing process at intervals provided for in such policies and procedures.

  • In addition, if Medical Group or Medical Group Provider is responsible in whole or in part for an identified Serious Reportable Event or HAC, Medical Group or Medical Group Provider agree that in no event shall Medical Group or Medical Group Provider ▇▇▇▇, charge collect a deposit from, seek compensation, remuneration or reimbursement from or have any recourse against Member for such identified Serious Reportable Event or HAC.

  • Medical Group Provider shall maintain accurate financial books and records, including electronic records, concerning Covered Services provided to each Member, including any charges to and payments received from the Member by Medical Group (“Financial Record”).

  • Any disallowance of Inpatient services as a result of any utilization review, quality assurance or peer review activity, identified Serious Reportable Event, or identified HAC shall be deducted from BCBSTX’s payment obligations to Medical Group or Medical Group Provider who is responsible in whole or in part for Serious Reportable Event or HAC.

  • Medical Group further agrees that: (a) this provision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the Subscriber; and (b) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Medical Group or a Medical Group Provider and Subscriber or persons acting on their behalf.

  • For patients claiming enrollment in BCBSTX, but not appearing on the membership list, Medical Group Provider shall request eligibility information by telephoning BCBSTX or by other electronic means established by BCBSTX.

  • Medical Group shall require that the Medical Group Provider provide patient records, reports and other documentation regarding such Subscriber at no cost upon request in order to facilitate such transfer.