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Health Care Services Agreement Page 4
Health Care Services Agreement
Family Planning One 4
HRA. "HRA" shall mean the Department of Social Services of the Human Resources Administration
of the City of New York.
MMIS. "MMIS" shall mean the Medicaid Management Information System of the New York State
Department of Social Services.
Medicaid Agreement. The "Medicaid Agreement" shall mean the contract for the provision of
Medicaid managed care services entered into by and between ABCHP and NEW YORK CITY or DOH as
the case may be, and all exhibits, attachments, amendments and addenda thereto. The Medicaid
Agreement is hereby incorporated by reference as if it were specifically set forth herein.
Medicaid Enrollee. “Medicaid Enrollee” shall mean an Enrollee who receives services under
ABCHP’s Medicaid program, in accordance with the Medicaid Agreement and applicable Benefit Plan.
Medical Record. "Medical Record" shall mean a complete record that documents care received
under the Benefit Package by the Enrollee, including inpatient, outpatient, and Emergency Services, in
accordance with all applicable laws, rules and regulations, and is signed by the medical professional(s)
rendering the services.
Medically Necessary. "Medically Necessary" shall mean Covered Services and supplies provided or
to be provided to an Enrollee under this Agreement that are: (i) timely, appropriate and necessary for the
symptoms, diagnosis, or treatment of the Enrollee's pathologic medical condition, illness, disease, or injury;
(ii) within standards of good medical practice as recognized and accepted by the medical community; (iii) not
primarily for the convenience of the Enrollee, the Enrollee's physician, or another provider of health services;
and (iv) the most efficient, economic, and appropriate service or supply which can be safely provided. In the
case of inpatient hospital services, Medically Necessary shall also mean that safe and adequate care could
not be provided to the Enrollee on an outpatient basis or in a less intensified treatment setting.
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Health Care Services Agreement