Refer to Sample Clauses

Refer to. Generally you will not have claims to file or papers to fill out in order for a claim to be paid. The Practitioner/Provider will ▇▇▇▇ us directly for the cost of services. Most services require Cost Sharing (Deductible, Coinsurance and/or Copayments) at the time of service. The amount of Cost Sharing for each service can be found in your Summary of Benefits and Coverage. In-network Practitioners and Providers cannot ▇▇▇▇ you for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/Providers to comply with any specified numbers, targeted averages, or maximum duration of patient visits. Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered Health Care Services obtained from an Out-of-network Practitioner/Provider or outside the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. You will not pay higher or additional Cost Sharing amounts under such circumstances. Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Otherwise, you will be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not Cover the services and you will be responsible for payment. Before the Medical Director may deny a request for specialist services that are unavailable from an In-Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a Prior Authorization to an Out-of-network Practitioner/Provider is reasonable, we will consider the following circumstances:  Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation.  Competency – The In-network Practitioner/Provider does no...

Refer to. Gateway must communicate and interface with a minimum of two thermostats:

Refer to. Appendix 1, Memorandum of Agreement. Grievance Procedures, pages 95.

Refer to. “LCMs shall be normally closed:

Refer to. Annual Leave Appendix 1, MOA, Page 58 Military Leave with Pay Appendix 1, MOA, Page 40 Call-up to Active Military Duty Appendix 1, MOA, Page 42 Leave of Absence without Pay Appendix 1, MOA, Page 46 Leave for Disaster Service Appendix 1, MOA, Page 49 Accident Leave Appendix 1, MOA, Page 50

Refer to. Article 31.3 for information re: the impact of a leave of absence on the probationary period.

Refer to. Anyone who knowingly presents a false or fraudulent claim for payment of a loss, or benefit or knowingly presents false information for services is guilty of a crime and may be subject to civil fines and criminal penalties. We may terminate your Coverage for any type of fraudulent activity. For further information regarding Fraud, refer to the General Provisions Section.

Refer to. Prior Auth Required /Emergency Health Services / Observation / Trauma Services, and Eligibility, Enrollment and Termination and Continuation Sections of this Agreement. This benefit has one or more exclusions as specified in the Exclusions section. Exclusion Refer to Prior Auth Required Prior Auth Required

Refer to. “Appendix 2. The Technology Team” for a detailed description of the composition of the team and functions of individual team members