Denial of Services Sample Clauses
A Denial of Services clause defines the circumstances under which a service provider may refuse or suspend the provision of services to a client. Typically, this clause outlines specific triggers such as non-payment, violation of terms, or illegal activity that justify the denial of access. By clearly stating these conditions, the clause helps protect the provider from misuse or abuse of services and ensures that clients are aware of the consequences of breaching the agreement.
Denial of Services. Provider shall not deny services to a Medicaid recipient during the period that the recipient is covered under the Medicaid fee-for-service program prior to the effective date of the recipient’s enrollment with Health Plan under the Medical Assistance Program.
Denial of Services. 3.5.9.2.1 If the Contractor denies a request for prior authorization, the Contractor must issue a Notice of Adverse Benefit Determination within 24 hours of receiving the request for prior authorization (see Section 3.15.2 of this Contract for Notice of Adverse Benefit Determination requirements).
3.5.9.2.2 In addition to including the minimum information specified in Section 3.15.2.3, the Notice of Adverse Benefit Determination must include information to direct the provider if further information or a change in prescription will allow for the treatment to be covered, including but not limited to: a first line or preferred product that would be covered, any missing documentation, whether the drug is not indicated for the member’s diagnosis, and specific elements of the approval criteria not documented on the request form.
Denial of Services. A determination made by a BH-MCO in response to a Provider's or Member’s request for approval to provide a service of a specific amount, duration and scope which:
Denial of Services. The closure of a case;
Denial of Services. The Primary Contractor’s BH-MCO must have a procedure that allows Members to grieve denials of requests for authorization for services. Individuals responsible for denying services or reviewing Grievances of denials must have the necessary and appropriate clinical training and experience. All denials must be made by a physician or, in some cases, by a licensed psychologist. Prior to denying services requested for an individual under 21, a peer-to-peer review must be conducted. Denials of inpatient care must be approved by a physician. Qualifications of individuals must be consistent with Appendix AA, and all applicable Commonwealth laws and regulations. The BH-MCO may not deny or reduce the amount, duration, or scope of a required service solely because of a Member’s diagnosis, type of illness or condition. If a service for which the request for authorization is denied is viewed by the prescriber and the Member as an Urgent or Emergency Service, the Primary Contractor’s BH-MCO must have a process for expedited review of such Grievances to occur within 24 hours of the request. Any time the Primary Contractor’s BH-MCO denies a request for authorization for service, the Primary Contractor’s BH-MCO must notify the Member or the parent/custodian of a child or adolescent, in writing. The written notification must include:
a. Specific reasons for the denial with references to the program provi- sions;
b. A description of alternative services recommended on the basis of placement criteria, e.g., Adult Placement Criteria for Drug and Alcohol services.
c. A description of the Member’s right to file a Grievance and/or request a DHS Fair Hearing.
d. Information for the Member describing how to file a Grievance and/or request a DHS Fair Hearing.
e. An offer by the BH-MCO to assist the Member in filing a Grievance and/or DHS Fair Hearing.
Denial of Services. Except for maintaining a non-dividend bearing share account and the right to vote in special and annual meetings, USALLIANCE may deny Federal Insurance: Member deposits are federally insured up to $250,000 by the National Credit Union Share Insurance Fund, which is administered by the National Credit Union Administration, a U.S. government agency.
Denial of Services. In the event that any Credit Union member or other Party becomes delinquent on any obligation to the Credit Union, causes us a loss or makes known his or her intention to cause us a loss, whether by way of loan default, account overdraft,
Denial of Services. The use of the EFT Services is a privilege of membership and not a right. In the event that the Primary Member or any other Party becomes delinquent on an obligation to us, causes us a loss, or makes known his or her intention to cause us a loss, whether by way of loan default, account overdraft, or otherwise, or in the event that a Primary Member or any other Party has been abusive in the conduct of his or her affairs with the Credit Union, including repeated overdrafts, it is our policy to restrict or terminate certain services extended to the Primary Member and/or other Parties, including without limitation, telephone, computer, and mobile access services and ATM and debit card services, and you acknowledge that we may do so. Any electronic access
Denial of Services. Except for maintaining a non-dividend bearing share account and the right to vote in special and annual meetings, USALLIANCE may deny all services to any member or any member of a credit union with which we have merged who has caused a financial loss, has engaged in fraud or forgery, or whose conduct is deemed inappropriate or abusive. Denial of services also means that you cannot conduct business on your behalf or on behalf of another. For security and regulatory reasons, there may be additional limitations on the type, dollar amount or number of transactions permitted at certain times to safeguard your accounts against misuse or when you have failed to follow proper procedures for accessing your accounts. Federal Insurance: Member deposits are federally insured up to $250,000 by the National Credit Union Share Insurance Fund, which is administered by the National Credit Union Administration, a U.S. government agency.
Denial of Services. Any determination made by the PH-MCO in response to a request for approval which: disapproves the request completely; or approves provision of the requested service(s), but for a lesser amount, scope or duration than requested; or disapproves provision of the requested service(s), but approves provision of an alternative service(s); or reduces, suspends or terminates a previously authorized service. An approval of a requested service which includes a requirement for a Concurrent Review by the PH-MCO during the authorized period does not constitute a Denial of Service. Denied Claim — An Adjudicated Claim that does not result in a payment obligation to a Provider. Department — The Department of Human Services of the Commonwealth of Pennsylvania. Deprivation Qualifying Code — The code specifying the condition which determines a Recipient to be eligible in nonfinancial criteria. Developmental Disability — A severe, chronic disability of an individual that is: Disease Management — An integrated treatment approach that includes the collaboration and coordination of patient care delivery systems and that focuses on measurably improving clinical outcomes for a particular medical condition through the use of appropriate clinical resources such as preventive care, treatment guidelines, patient counseling, education and outpatient care; and that includes evaluation of the appropriateness of the scope, setting and level of care in relation to clinical outcomes and cost of a particular condition. Disenrollment — The process by which a Member’s ability to receive services from a PH-MCO is terminated. DHS Fair Hearing — A hearing conducted by the Department Bureau of Hearings and Appeals. Drug Efficacy Study Implementation — Drug products that have been classified as less-than-effective by the FDA. Dual Eligible — An individual who is eligible to receive services through both Medicare and the MA Program. Durable Medical Equipment — Equipment furnished by a supplier or a home health agency that meets the following conditions: (a) can withstand repeated use