Xxxxxx Care Medical Home Services Sample Clauses

Xxxxxx Care Medical Home Services. The PIHP must provide FCMH services to the extent outlined below, but it is not restricted to only providing Medicaid services. Sometimes the PIHP may find that other treatment methods may be more appropriate than Medicaid covered services, or result in better outcomes. The PIHP may cover services for a member that are in addition to those services covered under the State plan per 42 CFR §438.3(e). In lieu of services can be covered the PIHP on a voluntary basis as follows: the state determines that the alternative service or setting is a medically appropriate and cost effective substitute for the covered service or setting under the state plan; the enrollee is not required by the PIHP to use the alternative service or setting; the approved in lieu of services are identified in the PIHP contract and will be provided at the option of the PIHP; and the utilization and cost of in lieu of services is taken into account in developing the component of the capitation rates that represent the covered state plan services None of the provisions of this Contract that are applicable to Medicaid covered services apply to other services that the PIHP may choose to provide, except that abortions, hysterectomies and sterilizations must comply with 42 CFR 441 Subpart E and 42 CFR 441 Subpart F. The Department will authorize the PIHP to substitute an appropriate alternative service for a covered service if the service meets four criteria: the service must be medically necessary; the service must be health-related; the service must be an appropriate substitute for a covered service; and the service must be cost-effective when compared to the covered service. These alternatives must be reported in the encounter reporting system using codes defined by the Department. Whether the service provided is a Medicaid covered service or an alternative service, the PIHP or PIHP provider is not allowed to bill the member for the service. Cost sharing is prohibited in the Xxxxxx Care Medical Home project.
Sample 1
AutoNDA by SimpleDocs
Xxxxxx Care Medical Home Services. The PIHP must provide FCMH services to the extent outlined below, but it is not restricted to only providing Medicaid services. Sometimes the PIHP finds that other treatment methods may be more appropriate than Medicaid covered services, or result in better outcomes. None of the provisions of this Contract that are applicable to Medicaid covered services apply to other services that the PIHP may choose to provide, except that abortions, hysterectomies and sterilizations must comply with 42 CFR 441 Subpart E and 42 CFR 441 Subpart F. The Department will authorize the PIHP to substitute an appropriate alternative service for a covered service if the service meets four criteria: the service must be medically necessary; the service must be health-related; the service must be an appropriate substitute for a covered service; and the service must be cost-effective when compared to the covered service. These alternatives must be reported in the encounter reporting system using codes defined by the Department. Whether the service provided is a Medicaid covered service or an alternative service, the PIHP or PIHP provider is not allowed to xxxx the member for the service. Cost sharing is prohibited in the Xxxxxx Care Medical Home project.
Sample 1

Related to Xxxxxx Care Medical Home Services

  • 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.

  • 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.

  • 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.

  • 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.

  • Medical Care The Parents must comply with the School Welfare Officer's recommendations which may include a reasonable decision to release the Pupil home or to his / her education guardian when s/he is unwell.

  • 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.

  • 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.

  • Child Care A. Employees employed as of March 1 who meet the following criteria shall be eligible for a lump sum payment each year. Eligible employees may apply for this payment between March 1 and April 15 of each year. Payment shall be made within thirty (30) days of receipt of the completed application. Any application received after April 15 will be considered on a case by case basis and shall not be arbitrarily rejected.

  • Chiropractic Services This plan covers chiropractic visits up to the benefit limit shown in the Summary of Medical Benefits. The benefit limit applies to any visit for the purposes of chiropractic treatment or diagnosis.

  • 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.

Time is Money Join Law Insider Premium to draft better contracts faster.