Emergency Healthcare Services Sample Clauses

Emergency Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, seven days per week, when those services are needed immediately to prevent jeopardy to your health. You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-Network facility at the In-network benefit level. Whether Out-of-network Emergency Healthcare Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive healthcare procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Healthcare Services Coverage for trauma services and all other Emergency Healthcare Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In- network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Healthcare Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency.
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Emergency Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, 7 days per week, when those services are needed immediately to prevent jeopardy to your health. You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-Network facility at the In-network benefit level. Whether Out-of-network Emergency Healthcare Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive healthcare procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: Jeopardy to the person’s health Serious impairment of bodily functions Serious dysfunction of any bodily organ or part Disfigurement to the person
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Emergency Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, seven days per week, when those services are needed immediately to prevent jeopardy to your health. If Emergency Healthcare Services are administered by either an In-network or Out-of-network Practitioner/Provider, benefits for the initial treatment are paid at the In-network benefit level. If you, as a result of Emergency Healthcare Services, are admitted to an Out-of-network Hospital, you may choose to be transferred to a Hospital that is in our Practitioner/Provider PPO network (In-network). You must be medically stable and able to be safely transferred. Refer to Ambulance Services in the Summary of Benefits and Coverage for the required Cost Sharing for inter-facility transportation costs. If you choose to remain at an Out-of-network Hospital after you are medically stable and able to be safely transferred, Out-of-network benefits will apply. We will provide reimbursement when you receive healthcare procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person
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Emergency Healthcare Services. This Agreement covers acute Emergency Healthcare Services 24 hours per day, seven (7) days per week, when those services are needed immediately to prevent jeopardy to your health. You should seek medical treatment from an In-network Practitioner/Provider or facility whenever possible. If you cannot reasonably access an In-network Facility, we will arrange to Cover the care at an Out-of-network (outside of the 5-county area) facility at the In-network benefit level. Whether Out-of-network (outside of the 5-county area) Emergency Healthcare Service is appropriate will be determined by the Reasonable/Prudent Layperson standard discussed below. We will provide reimbursement when you receive healthcare procedures, treatments or services delivered after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: • Jeopardy to the person’s health • Serious impairment of bodily functions • Serious dysfunction of any bodily organ or part • Disfigurement to the person • Any circumstance that prevented you from using our established procedures for obtaining Emergency Healthcare Services Coverage for trauma services and all other Emergency Healthcare Services will continue at least until you are medically stable, do not require critical care, and can be safely transferred to an In- network facility based on the judgment of the attending Physician in consultant with us and in accordance with federal law. We will provide reimbursement when you, acting in good faith, obtain Emergency Healthcare Services for what reasonably appears to you, acting as a Reasonable/Prudent Layperson, to be an acute condition that requires immediate medical attention, even if your condition is later determined to not be an emergency. Prior Authorization is not required for Emergency Healthcare Services. If you are admitted as an Inpatient to the Hospital, you or your Practitioner needs to notify us as soon as possible so we can review your Hospital stay. We will not deny a claim for Emergency Health services when the Member was referred to the emergency room by his or her PCP or by our representative. If your Emergency Health services results in a hospitalization directly from the emergency room, you are responsible for paying the Inpatient Hospital Cost Sharing amounts (Deductible, Coins...
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Related to Emergency Healthcare Services

  • COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

  • Emergency Care Services If you experience a medical emergency while traveling outside our service area, go to the nearest emergency or urgent care facility. When you receive Out-of-Area covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for the Out-of-Area Covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of: • the billed charges for your Out-of-Area covered healthcare services; or • the negotiated price that the Host Blue makes available to us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.

  • Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

  • Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.

  • Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.

  • Emergency Medical Services The City’s Fire Department and MedStar (or other entity engaged by the City after the Effective Date) will provide emergency medical services.

  • Pharmacy Services The Contractor shall establish a network of pharmacies. The Contractor or its PBM must provide at least two (2) pharmacy providers within thirty (30) miles or thirty (30) minutes from a member’s residence in each county, as well as at least two (2) durable medical equipment providers in each county or contiguous county.

  • Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.

  • Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.

  • Community Mental Health Center Services Assertive Community Treatment Staffing Full Time Equivalents Community Mental Health Center March 2021 December 2020 Nurse Masters Level Clinician/or Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner 01 Northern Human Services - Wolfeboro 1.00 0.00 0.00 0.57 6.81 0.27 8.27 0.25 01 Northern Human Services - Berlin 0.34 0.31 0.00 0.00 3.94 0.14 4.17 0.14 01 Northern Human Services - Littleton 0.00 0.14 0.00 0.00 3.28 0.29 3.31 0.29 02 West Central Behavioral Health 0.60 1.00 0.00 0.00 5.40 0.30 5.90 0.30 03 Lakes Region Mental Health Center 1.00 1.00 0.00 1.00 5.00 0.40 7.00 0.38 04 Riverbend Community Mental Health Center 0.50 1.00 6.90 1.00 10.40 0.50 10.50 0.50 05 Monadnock Family Services 1.91 2.53 0.00 1.12 11.17 0.66 10.32 0.62 06 Greater Nashua Mental Health 1 1.00 1.00 3.00 1.00 7.65 0.15 8.50 0.15 06 Greater Nashua Mental Health 2 1.00 1.00 4.00 1.00 8.65 0.15 8.50 0.15 07 Mental Health Center of Greater Manchester-CTT 1.33 10.64 2.00 0.00 19.95 1.17 21.61 1.21 07 Mental Health Center of Greater Manchester-MCST 1.33 9.31 3.33 1.33 19.95 1.17 25.27 1.21 08 Seacoast Mental Health Center 1.00 1.10 5.00 1.00 10.10 0.60 10.10 0.60 09 Community Partners 0.50 0.00 3.40 0.88 7.28 0.70 7.41 0.70 10 Center for Life Management 1.00 0.00 2.28 1.00 6.71 0.46 6.57 0.46 Total 12.51 29.03 29.91 9.33 126.29 6.96 137.43 6.96 2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies Community Mental Health Center Substance Use Disorder Treatment Housing Assistance Supported Employment March 2021 December 2020 March 2021 December 2020 March 2021 December 2020 01 Northern Human Services - Wolfeboro 1.27 1.27 5.81 6.30 0.00 0.40 01 Northern Human Services - Berlin 0.74 0.74 3.29 3.29 0.00 0.23 01 Northern Human Services - Littleton 1.43 1.29 2.14 2.14 1.00 1.00 02 West Central Behavioral Health 0.20 0.20 4.00 0.40 0.60 0.60 03 Lakes Region Mental Health Center 1.00 3.00 5.00 7.00 2.00 2.00 04 Riverbend Community Mental Health Center 0.50 0.50 9.40 9.50 0.50 0.50 05 Monadnock Family Services 1.69 1.62 4.56 4.48 0.95 1.18 06 Greater Nashua Mental Health 1 6.15 7.15 5.50 6.50 1.50 1.50 06 Greater Nashua Mental Health 2 5.15 5.15 6.50 6.50 0.50 0.50 07 Mental Health Center of Greater Manchester-CCT 14.47 15.84 13.96 15.62 2.66 2.66 07 Mental Health Center of Greater Manchester-MCST 6.49 7.86 15.29 19.28 1.33 2.66 08 Seacoast Mental Health Center 2.00 2.00 5.00 5.00 1.00 1.00 09 Community Partners 1.20 1.20 4.50 4.50 1.00 1.00 10 Center for Life Management 2.14 2.14 5.42 5.28 0.29 0.29 Total 44.43 49.96 90.37 99.39 13.33 15.52 Revisions to Prior Period: None. Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report. Notes: Data compiled 04/26/2021. For 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.

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