Access to Covered Services Sample Clauses

The 'Access to Covered Services' clause defines the rights and procedures by which individuals or entities can utilize specific services provided under an agreement or plan. Typically, this clause outlines eligibility requirements, the process for requesting services, and any limitations or conditions that may apply, such as prior authorization or network restrictions. Its core practical function is to ensure that all parties understand how and when services can be accessed, thereby reducing confusion and disputes regarding service availability.
Access to Covered Services. Provider shall make necessary and appropriate arrangements to ensure the availability of Covered Services to Members twenty-four (24) hours per day and seven (7) days per week.
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Access to Covered Services. Urgent Care must be provided within twenty-four (24) hours [42 CFR §438.206(c)(1)(i)]. Urgent care may be provided directly by the provider or as directed by the DBPM through other arrangements. Routine or preventative dental services should be provided within six (6) weeks. Wait times for scheduled appointments should not routinely exceed forty-five (45) minutes, including time spent in the waiting room and the examining room, unless the provider is unavailable or delayed because of an emergency. If a provider is delayed, the member should be notified immediately. If a wait of more than ninety (90) minutes is anticipated, the member should be offered a new appointment.
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Related to Access to Covered Services

  • Covered Services You will receive Covered Services under the terms and conditions of this Contract only when the Covered Service is: • Medically Necessary; • Provided by a Participating Provider for in-network coverage; • Listed as a Covered Service; • Not in excess of any benefit limitations described in the Schedule of Benefits section of this Contract; and • Received while Your Contract is in force.

  • Provision of Covered Services MCP is responsible for authorizing Medically Necessary Covered Services, including NSMHS, ensuring MCP’s Network Providers coordinate care for Members as provided in the applicable Medi-Cal Managed Care Contract, and coordinating care from other providers of carve-out programs, services, and benefits.

  • Non-Covered Services The Contractor shall refer Members to Providers enrolled in the Medicaid Fee-for- Service delivery system for all Medically Necessary Services not covered by the Contractor under the MississippiCAN Program. The Contractor shall have written policies and procedures for the referral of Members for non-covered services, which shall provide for the smooth transition to Out-of-network Providers and assistance to Members in obtaining a new PCP, if appropriate. These procedures shall be applicable to the referral of Members to Out-of- network Providers, as necessary, upon Disenrollment, regardless of the reasons for Disenrollment.

  • 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. This plan covers the following preventive office visits. • Annual preventive visit - one (1) routine physical examination per plan year per • 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.

  • Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Must be performed by a certified home health care agency. 0% - After deductible Not Covered