Medically Frail Determination Sample Clauses

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows:  150 debit points for indicated medical conditions; EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK  150 debit points for combined indicated medical, behavioral health and substance abuse conditions;  75 debit points for indicated behavioral health conditions;  75 debit points for indicated substance abuse conditions; or  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the...
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Related to Medically Frail Determination

  • Benefit Level Two Health Care Network Determination Issues regarding the health care networks for the 2017 insurance year shall be negotiated in accordance with the following procedures:

  • Medically Necessary In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Contract.

  • Independence from Material Breach Determination Except as set forth in Section X.D.1.c, these provisions for payment of Stipulated Penalties shall not affect or otherwise set a standard for OIG’s decision that CHSI has materially breached this CIA, which decision shall be made at OIG’s discretion and shall be governed by the provisions in Section X.D, below.

  • MEDICALLY FRAGILE STUDENTS 1. If a teacher will be providing instructional or other services to a medically fragile student, the teacher or another adult who will be present when the instruction or other services are being provided will be advised of the steps to be taken in the event an emergency arises relating to the student's medical condition.

  • Medically Necessary Services for the State plan services in Addendum VIII. B medically necessary has the meaning in Wis. Admin. Code DHS §101.03(96m): services (as defined under Wis. Stat. § 49.46

  • Final Determination His/her determination is final unless, within ten (10) days after notification, a recognized employee organization requests in writing to meet and confer thereon.

  • Salary Determination 12.5.1 A unit member shall receive a salary not less than the minimum salary nor more than the maximum salary (Articles 12.3 and 12.4) for the rank to which appointed, except as provided in Articles 4.15, 5.6, 10.6.1 or Article 10.6.1.1. The effective dates for salaries shall be the appropriate dates specified in Article 12.2.2.

  • CHILD AND DEPENDENT ADULT/ELDER ABUSE REPORTING CONTRACTOR shall establish a procedure acceptable to ADMINISTRATOR to ensure that all employees, agents, subcontractors, and all other individuals performing services under this Agreement report child abuse or neglect to one of the agencies specified in Penal Code Section 11165.9 and dependent adult or elder abuse as defined in Section 15610.07 of the WIC to one of the agencies specified in WIC Section 15630. CONTRACTOR shall require such employees, agents, subcontractors, and all other individuals performing services under this Agreement to sign a statement acknowledging the child abuse reporting requirements set forth in Sections 11166 and 11166.05 of the Penal Code and the dependent adult and elder abuse reporting requirements, as set forth in Section 15630 of the WIC, and shall comply with the provisions of these code sections, as they now exist or as they may hereafter be amended.

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • Preventive Care and Early Detection Services This plan covers, early detection services, preventive care services, and immunizations or vaccinations in accordance with state and federal law, including the Affordable Care Act (ACA), as set forth below and in accordance with the guidelines of the following resources: • services that have an A or B rating in the current recommendations of the U.S. Preventative Services Task Force (USPSTF); • immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; • preventive care and screenings for infants, children, and adolescents as outlined in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); or • preventive care and screenings for women as outlined in the comprehensive guidelines as supported by HRSA. Covered early detection services, preventive care services and adult and pediatric immunizations or vaccinations are based on the most currently available guidelines and are subject to change. The amount you pay for preventive services will be different from the amount you pay for diagnostic procedures and non-preventive services. See the Summary of Medical Benefits and the Summary of Pharmacy Benefits for more information about the amount you pay. Preventive Office Visits This plan covers the following preventive office visits. • Annual preventive visit - one (1) routine physical examination per plan year per member age 36 months and older; • Pediatric preventive office and clinic visits from birth to 35 months - 11 visits; • Well Woman annual preventive visit - one (1) routine gynecological examination per plan year per female member.

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