Managed Care Program Services Sample Clauses

The "Managed Care Program Services" clause defines the responsibilities and scope of services provided by a party in administering or supporting a managed care program. Typically, this clause outlines the specific healthcare management activities, such as coordinating patient care, processing claims, or ensuring provider network adequacy, that the service provider must perform. By clearly delineating these obligations, the clause ensures that both parties understand the expectations and standards for managed care delivery, thereby reducing misunderstandings and promoting efficient program administration.
Managed Care Program Services. Consistent with the requirements of State and Federal Law and the standards of Accreditation Organizations, PacifiCare shall be accountable for the performance of the following services for all Managed Care Plans: (i) quality management and improvement, (ii) utilization management, (iii) credentialing, (iv) Member rights and responsibilities, (v) preventive health services, (vi) medical record review and (vii) payment and processing of claims (collectively, “Managed Care Program Services”). Medical Group and its Participating Providers shall cooperate with PacifiCare in the performance of all Managed Care Program Services and conduct their activities in a manner consistent with the provisions of this Article 4 including specifically, but without limitation, PacifiCare’s QI Program, UM Program, Credentialing Program, Member Services activities, and Claims Processing Guidelines.
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Managed Care Program Services. 4.1 MANAGED CARE PROGRAM SERVICES. Health Plan shall be accountable for the performance of the following services for all Managed Care Plans: (I) quality management and improvement, (ii) utilization management, (iii) credentialing, (iv) member rights and responsibilities, (v) preventive health services, (vi) medical record review and (vii) payment and processing of claims (collectively, "Managed Care Program Services"). Medical Group and its Participating Providers shall participate, cooperate and comply with Health Plan in the performance of all Managed Care Program Services. Specific activities related to utilization management, credentialing and claims processing may be delegated by Health Plan to Medical Group at such time as Medical Group demonstrates to Health Plan's satisfaction the ability to perform these functions in compliance with Health Plan's standards, as amended from time to time. Before the performance of any activities is delegated to Medical Group, Health Plan shall conduct a comprehensive audit of Medical Group's ability and administrative capacity to perform such activities. Medical Group shall provide all documentation requested by Health Plan and shall provide Health Plan representatives with on-site access to Medical Group's facilities and personnel for purposes of conducting such audit.
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Managed Care Program Services. PacifiCare shall be accountable for the performance of the following services for all Managed Care Plans: (i) quality management and improvement, (ii) utilization management, (iii) credentialing, (iv) member rights and responsibilities, (v) preventive health services, (vi) medical record review and (vii) payment and processing of claims (collectively, "Managed Care Program Services"). Medical Group and its Participating Providers shall participate, cooperate and comply with PacifiCare in the performance of all Managed Care Program Services. Specific activities related to utilization management, credentialing and claims processing may be delegated by PacifiCare to Medical Group in accordance with the provisions of this Article 4. Before the performance of any activities is delegated to Medical Group, PacifiCare shall conduct a comprehensive audit of Medical Group's ability and administrative capacity to perform such activities. Medical Group shall provide all reasonable documentation requested by PacifiCare and shall provide PacifiCare representatives with on-site access to Medical Group's facilities and personnel for purposes of conducting such audit.
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Managed Care Program Services. Provider agrees to abide by the Health Plan’s or Payor’s policies and procedures pertaining to the administration of Health Benefit Program services and to abide by all Provider Manuals issued by the Health Plan or Payor. The applicable policies and procedures may include, but not be limited to, policies and procedures pertaining to the Health Plan’s or Payor’s Utilization Management (“UM”) Program, Quality Management (“QM”) Program, Credentialing Program, and Claims Processing Guidelines. Such policies and procedures will outline the non-delegated requirements for claims submission, subcontract rate information, utilization management, and credentialing.
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Managed Care Program Services. Consistent with the requirements of state and federal law and the standards of accreditation organization, Health Plan or the Payor shall be accountable for the performance of the following services for all Health Benefit Programs: i. quality management and improvement, ii. utilization management, iii. credentialing,
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Managed Care Program Services 
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Related to Managed Care Program Services

  • Program Services a) Personalized Care Practice agrees to provide to Program Member certain enhancements and amenities to professional medical services to be rendered by Personalized Care Practice to Program Member, as further described in Schedule 1 to these Terms. Upon prior written notice to Program Member, Personalized Care Practice may add or modify the Program Services set forth in Schedule 1, as reasonably necessary, and subject to such additional fees and/or terms and conditions as may be reasonably necessary. b) Program Member acknowledges that the Program Services are services that are not covered services under any insurance contract to which Program Member may be a party, including, without limitation, Medicare, and are not reimbursable by Program Member’s insurer, health plan or any governmental entity, including Medicare. Program Member agrees to bear sole financial responsibility for the Member Amenities Fee and agrees not to submit to Program Member’s insurer, health plan or governmental entity any ▇▇▇▇, invoice or claim for payment or reimbursement of such Member Amenities Fee. c) Personalized Care Practice or its designated affiliate will separately charge Program Member or Program Member’s insurer, health plan or governmental entity for medical, clinical, diagnostic or therapeutic services rendered by Personalized Care Practice or its designated affiliate to Program Member, and Program Member may seek payment or reimbursement from Program Member’s insurer or health plan for any such service to the extent covered by Program Member’s insurer, health plan or governmental entity. d) Program Member understands, agrees and covenants that this Agreement is a service contract, and not a contract for insurance.

  • Pharmacy Services The Contractor agrees to comply with the requirements regarding covered pharmacy and over-the- counter (OTC) benefits. The Contractor will comply with the EOHHS Pharmacy Home Program and the Generics First Initiative, including the maintenance of the drug formulary in accordance with the direction of the EOHHS Pharmacy Committee.

  • 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.

  • Marketing Services The Manager shall provide advice and assistance in the marketing of the Vessels, including the identification of potential customers, identification of Vessels available for charter opportunities and preparation of bids.

  • 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.