Provision of Covered Services Clause Samples

Provision of Covered Services. Contractor shall require each Participating Provider to ensure that each subcontracting arrangement entered into by each Participating Provider complies with the applicable terms and conditions set forth in the Agreement, as mutually agreed upon by Covered California and Contractor, and which may include the following: i. Coordination with Covered California and other programs and stakeholders (Section 3.1); ii. Relationship of the parties as independent contractors (Section 1.3(a)) and Contractor’s exclusive responsibility for obligations under the Agreement (Section 1.3(b)); iii. Participating Provider Directory requirements (Section 4.4.4);

Provision of Covered Services. Contractor shall require each Participating Provider to ensure that each subcontracting arrangement entered into by each Participating Provider complies with the applicable terms and conditions set forth in the Agreement, as mutually agreed upon by Covered California and Contractor, and which may include the following: i. Coordination with Covered California and other programs and stakeholders (Section 3.1); ii. Relationship of the parties as independent contractors (Section 1.3(a)) and Contractor’s exclusive responsibility for obligations under the Agreement (Section 1.3(b)); iii. Participating Provider Directory requirements (Section 4.4.4); iv. Symphony Provider Directory requirements (Section 4.4.5); v. Implementation of processes to enhance stability and minimize disruption to provider network (Section 4.3.2); vi. Notices, network requirements and other obligations relating to costs of out- of-network services and other benefits (Section 4.4.3); vii. Provider credentialing, including maintenance of licensure and insurance (Section 4.4.2); viii. Customer service standards (Section 4.6); ix. Utilization management (Section 5.3); x. Maintenance of a corporate compliance program (Section 1.2); xi. Enrollment and eligibility determinations and collection practices (Article 2); xii. Appeals and grievances (Section 4.6.2); xiii. Enrollee and marketing materials (Section 3.2); xiv. Disclosure of information required by Covered California, including if applicable, financial and clinical (Section 1.12); Advancing Equity, Quality, and Value (Article 5) and other data, books and records (Article 12); xv. Nondiscrimination (Section 1.10); xvi. Conflict of interest and integrity (Section 1.11); xvii. Other laws (Section 1.13); xviii. Quality, Network Management and Delivery System Standards and Improvement Strategy to the extent applicable to Participating Providers (Article 5), including, disclosure of contracting arrangements with Participating Providers as required pursuant to Attachment 1 - “Advancing Equity, Quality, and Value”. xix. Performance Measures, to the extent applicable to Participating Providers (Article 8); xx. Continuity of care, coordination and cooperation upon termination of Agreement and transition of Covered California Enrollees, if applicable (Article 9); xxi. Security and privacy requirements, including compliance with HIPAA (Article 11); and xxii. Maintenance of books and records (Article 12

Provision of Covered Services. Medical Group and its Participating Providers shall provide Covered Services to Commercial Plan Members pursuant to the terms of the Base Agreement and this Product Attachment A.

Provision of Covered Services. Agency is responsible for services provided or made available by Agency.

Provision of Covered Services. Provider may not refuse to provide Medically Necessary or preventive Covered Services to a child under the age of twenty-one (21) or other Covered Persons for non-medical reasons. Provider is not required to accept or continue treatment of a patient with whom Provider feels he or she cannot establish and/or maintain a professional relationship. Provider shall follow the applicable CRA’s requirements for the provision of Covered Services. Provider’s decisions affecting the delivery of acute or chronic care services to Covered Persons shall be made on an individualized basis and in accordance with the following definitions:

Provision of Covered Services. Provider shall furnish to Medi-Cal Members those services which is authorized to provide under this Agreement, consistent with the scope of Provider’s license, certification or accreditation, and in accordance with professionally recognized standards. Provider shall provide services to Medi-Cal Members in accordance with, and shall otherwise comply with, all of the provisions of the Plan Contract, including but not limited to all Exhibits, with respect to Medi-Cal Members enrolled in Health Plan through the Local Initiative.

Provision of Covered Services. Contractor shall undertake commercially reasonable efforts to ensure that each Participating Provider Agreement and each subcontracting arrangement entered into by each Participating Provider complies with the applicable terms and conditions set forth in this Agreement, as mutually agreed upon by the Exchange and Contractor, and which may include the following: i. Coordination with the Exchange and other programs and stakeholders; ii. Relationship of the parties as independent contractors (Section 1.3(a)) and Contractor’s exclusive responsibility for obligations under the Agreement (Section 1.3(b)); iii. Participating Provider directory requirements (Section 3.4.4);

Provision of Covered Services. Provider shall provide Covered Services to Members, within the scope of Provider’s license, in accordance with this Agreement, Health Plan’s policies and procedures, the terms and conditions of the Health Plan product which covers the Member, and the requirements of any applicable government sponsored program.

Provision of Covered Services. Participating Provider agrees to and shall participate in all Health Benefits Plans as may be required by QualCare hereunder. Participating Provider agrees to and shall provide, and arrange for the provision of, Covered Services, including without limitation Emergency services and Urgently Needed Services, as applicable, to Members pursuant to such Plans, pursuant to such Payor Agreements entered into between QualCare and the applicable Payors, pursuant to this Agreement, and pursuant to the Provider Manual, and shall comply with, and shall arrange for compliance with, all of the terms and conditions of each Payor Agreement, this Agreement, and the Provider Manual; provided, however, that the Payor Agreement, this Agreement, or the Provider Manual shall not require Participating Provider to provide services, charge of a fee, or engage in activities that would cause Participating Provider to be in violation of any applicable law, rule, or regulation. Such Covered Services shall be within the Participating Provider’s license, certification, and authorization as well as scope of service or specialty, consistent with standards prevailing in the community at the time the Covered Services are rendered.