CONTRACTOR AND DMAHS SERVICE EXCLUSIONS Clause Samples
The "CONTRACTOR AND DMAHS SERVICE EXCLUSIONS" clause defines which services or responsibilities are not covered by either the contractor or the Division of Medical Assistance and Health Services (DMAHS) under the agreement. This clause typically lists specific tasks, obligations, or types of work that both parties agree are outside the scope of the contract, such as certain medical procedures, administrative duties, or support services. By clearly outlining these exclusions, the clause helps prevent misunderstandings and disputes by ensuring both parties know which services are not expected or required, thereby clarifying the boundaries of their contractual obligations.
CONTRACTOR AND DMAHS SERVICE EXCLUSIONS. Neither the Contractor nor DMAHS shall be responsible for the following:
A. All services not medically necessary, provided, approved or arranged by a Contractor’s physician or other provider (within his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures.
E. Respite Care (except for MLTSS Members).
F. Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and accommodations, telephone charges, travel expenses other than those services in Article 4.1 of this contract, take home supplies and similar cost. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by the Contractor.
G. Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto.
H. All claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans Administration hospitals.
I. Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age.
J. Services provided to all persons without charge. Services and items provided without charge through programs of other public or voluntary agencies shall be utilized to the fullest extent possible.
K. Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military.
L. Payments to outside the United States and territories pursuant to N.J.S.A. 52:34-13.2 and section 6505 of the Affordable Care Act of 2010 which amends section 1902(a) of the Social Security Act.
M. Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers’ compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the Medicaid beneficiary claims or rece...
CONTRACTOR AND DMAHS SERVICE EXCLUSIONS. Neither the contractor nor DMAHS shall be responsible for the following:
A. All services not medically necessary, provided, approved or arranged by a contractor's physician or other provider (within his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures.
E. Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and accommodations, telephone charges, travel expenses other than those services not in Article 4.1 of this contract, take home supplies and similar cost. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by the contractor.
F. Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto.
G. All claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans Administration hospitals.
H. Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age.
I. Services provided to all persons without charge. Services and items provided without charge through programs of other public or voluntary agencies (for example, New Jersey State Department of Health and Senior Services, New Jersey Heart Association, First Aid Rescue Squads, and so forth) shall be utilized to the fullest extent possible.
J. Services or items furnished for any sickness or injury occurring while the covered person is on active duty in the military.
K. Services provided outside the United States and territories.
L. Services or items furnished for any condition or accidental injury arising out of and in the course of employment for which any benefits are available under the provisions of any workers' compensation law, temporary disability benefits law, occupational disease law, or similar legislation, whether or not the Medicaid beneficiary claims or receives benefits thereunder, and wh...
CONTRACTOR AND DMAHS SERVICE EXCLUSIONS. Neither the contractor nor DMAHS shall be responsible for the following:
A. All services not medically necessary, provided, approved or arranged by a contractor's physician or other provider (within his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
C. Experimental organ transplants.
CONTRACTOR AND DMAHS SERVICE EXCLUSIONS. Neither the contractor nor DMAHS shall be responsible for the following:
A. All services not medically necessary, provided, approved or arranged by a contractor’s physician or other provider (within his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures.
E. Respite Care
F. Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and accommodations, telephone charges, travel expenses other than those services not in Article 4.1 of this contract, take home supplies and similar cost. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by the contractor.
G. Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto.
CONTRACTOR AND DMAHS SERVICE EXCLUSIONS. Neither the contractor nor DMAHS shall be responsible for the following:
A. All services not medically necessary, provided, approved or arranged by a contractor's physician or other provider (within his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved,
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of infertility, .including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical procedures.
E. Respite Care
F. Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and accommodations, telephone charges, travel expenses other than those services not in Article 4.1 of this contract, take home supplies and similar cost, Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by the contractor.
G. Services involving the use of equipment in facilities, the purchase, rental or construction of which has not been approved by applicable laws of the State of New Jersey and regulations issued pursuant thereto,
H. All claims arising directly from services provided by or in institutions owned or operated by the federal government such as Veterans Administration hospitals.
I. . Services provided in an inpatient psychiatric institution, that is not an acute care hospital, to individuals under 65 years of age and over 21 years of age,
CONTRACTOR AND DMAHS SERVICE EXCLUSIONS. Neither the contractor nor DMAHS shall be responsible for the following:
A. All services not medically necessary, provided, approved or arranged by a contractor’s physician or other provider (within his/her scope of practice) except emergency services.
B. Cosmetic surgery except when medically necessary and approved.
C. Experimental organ transplants.
D. Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services, radiological and diagnostic services and surgical-procedures.
E. Respite Care
F. Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and accommodations, telephone charges, travel expenses other than those services not in Article 4.1 of this contract, take home supplies and similar cost. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered under EPSDT by the contractor.