Common use of Eligibility File Clause in Contracts

Eligibility File. The compilation of all Eligibility Information for an Enrollee or group of Enrollees into a single electronic format used to store or transmit the data. Employee – A “qualified Employee,” as defined in 45 C.F.R. 155.20. Employer – A “qualified Employer,” as defined in § 1312(f)(2) of the Act. Encounter – Any dental service or bundle of related dental services provided to one Enrollee by one Health Care Professional within one time period. Any dental services provided must be recorded in the Enrollee’s health record. Encounter Data – Encounter information Contractor can use to demonstrate the provision of dental services to Enrollees. Enrollee – Enrollee means each and every individual or an Employee and each of their Family Members enrolled in a QDP offered through the Exchange for the purpose of receiving health benefits. An Enrollee may be referred to as a member of a QDP who is entitled to receive covered services. Evidence of Coverage (EOC) and Disclosure Form – The booklet(s) which describe(s) the benefits, exclusions, limitations, conditions, and the benefit levels of the applicable Plan(s). The Exchange – The California Health Benefit Exchange, doing business as Covered California and an independent entity within the State of California. Explanation of Benefits (EOB) – A statement sent from the Contractor to an Enrollee listing services provided, amount billed, eligible expenses and payment made by the Plan. Explanation of Payment (EOP) – A statement sent from the Contractor to Providers detailing payments made for Health Care Services. Family Dental Plan – A plan certified by the Exchange that provides the pediatric dental benefits required in Health and Safety Code 1367.005(a)(5) and Insurance Code 10122.27(a)(5), and also includes coverage for certain benefits for adult Enrollees. Family Member – An individual who is within an Enrollee’s or Employee’s family, as defined in 26 U.S.C. 36B (d)(1). General Agent – A licensed insurance brokerage firm, qualified and operating under the laws of the state of California, with a network of affiliated Agents in the state of California, that is contracted with the Exchange. Grace Period – A specified time following the premium due date during which coverage remains in force and an Enrollee or Employer or other authorized person or entity may pay the premium without penalty. Health Care Professional – An individual with current and appropriate licensure, certification, or accreditation in a medical, dental or behavioral health profession, including without limitation, medical doctors (including psychiatrists), dentists, osteopathic physicians, psychologists, registered nurses, nurse practitioners, licensed practical nurses, certified medical assistants, licensed physician assistants, mental health professionals, chemical dependency counselors, clinical laboratory professionals, allied health care professionals, pharmacists, social workers, physical therapists, occupational therapists, and others to provide Health Care Services. Health Information Technology for Economic and Clinical Health Act (HITECH Act) – The Health Information Technology for Economic and Clinical Health Act, which was enacted as part of the American Recovery and Reinvestment Act of 2009, and the regulations issued pursuant thereto or as thereafter amended. Health Insurance Portability and Accountability Act of 1996 (HIPAA) – The Health Insurance Portability and Accountability Act of 1996 and the regulations issued pursuant thereto or as thereafter amended. Health Insurance Regulators – CDI and DMHC, as applicable. Individual Exchange – The Exchange through which Qualified Individuals may purchase QDPs. Individually Identifiable Health Information (IIHI) – The “individually identifiable health information” as defined under HIPAA. Information Practices Act (IPA) – The California Information Practices Act, Civil Code § 1798, et seq. and the regulations issued pursuant thereto or as thereafter amended. Insurance Information and Privacy Protection Act (IIPPA) – The California Insurance Information and Privacy Protection Act, Insurance Code §§ 791-791.28, et seq., and the regulations issued pursuant thereto or as thereafter amended.

Eligibility File. The compilation of all Eligibility Information for an Enrollee or group of Enrollees into a single electronic format used to store or transmit the data. Employee – A “qualified Employeeemployee,” as defined in 45 C.F.R. 155.20. Employer – A “qualified Employeremployer,” as defined in § Section 1312(f)(2) of the Act. Encounter – Any dental service or bundle of related dental services provided to one Enrollee by one Health Care Professional within one time period. Any dental services provided must be recorded in the Enrollee’s health record. Encounter Data – Encounter information Contractor can use to demonstrate the provision of dental services to Enrollees. Enrollee – Enrollee means each and every individual or an Employee and each of their Family Members enrolled in a QDP offered through the Exchange for the purpose of receiving health benefits. An Enrollee may be referred to as a member of a QDP who is entitled to receive covered services. Evidence of Coverage (EOC) and Disclosure Form – The booklet(s) which describe(s) the benefits, exclusions, limitations, conditions, and the benefit levels of the applicable Plan(s). The Exchange – The California Health Benefit Exchange, doing business as Covered California and an independent entity within the State of California. Explanation of Benefits (EOB) – A statement sent from the Contractor to an Enrollee listing services provided, amount billed, eligible expenses and payment made by the Plan. Explanation of Payment (EOP) – A statement sent from the Contractor to Providers detailing payments made for Health Care Services. Family Dental Plan – A plan certified by the Exchange that provides the pediatric dental benefits required in Health and Safety Code 1367.005(a)(5) and Insurance Code 10122.27(a)(5), and also includes coverage for certain benefits for adult Enrollees. Family Member – An individual who is within an Enrollee’s or Employee’s family, as defined in 26 U.S.C. 36B (d)(1). General Agent – A licensed insurance brokerage firm, qualified and operating under the laws of the state of California, with a network of affiliated Agents in the state of California, that is contracted with the Exchange. Grace Period – A specified time following the premium due date during which coverage remains in force and an Enrollee or Employer or other authorized person or entity may pay the premium without penalty. Health Care Professional – An individual with current and appropriate licensure, certification, or accreditation in a medical, dental or behavioral health profession, including without limitation, medical doctors (including psychiatrists), dentists, osteopathic physicians, psychologists, registered nurses, nurse practitioners, licensed practical nurses, certified medical assistants, licensed physician assistants, mental health professionals, chemical dependency counselors, clinical laboratory professionals, allied health care professionals, pharmacists, social workers, physical therapists, occupational therapists, and others to provide Health Care Services. Health Information Technology for Economic and Clinical Health Act (HITECH Act) – The Health Information Technology for Economic and Clinical Health Act, which was enacted as part of the American Recovery and Reinvestment Act of 2009, and the regulations issued pursuant thereto or as thereafter amended. Health Insurance Portability and Accountability Act of 1996 (HIPAA) – The Health Insurance Portability and Accountability Act of 1996 and the regulations issued pursuant thereto or as thereafter amended. Health Insurance Regulators – CDI and DMHC, as applicable. Individual Exchange – The Exchange through which Qualified Individuals may purchase QDPs. Individually Identifiable Health Information (IIHI) – The “individually identifiable health information” as defined under HIPAA. Information Practices Act (IPA) – The California Information Practices Act, Civil Code § 1798, et seq. and the regulations issued pursuant thereto or as thereafter amended. Insurance Information and Privacy Protection Act (IIPPA) – The California Insurance Information and Privacy Protection Act, Insurance Code §§ 791-791.28, et seq., and the regulations issued pursuant thereto or as thereafter amended.