Adjudication of Claims. 5.4.1 Adjudicating and processing claims of Members at the appropriate price, based on the agreement between WellPoint and the pharmacy provider, at the point-of-sale.
Adjudication of Claims. All claims administered under this Agreement shall be adjudicated in accordance with the terms and conditions of the applicable policy, contract or plan document, subject to Southern’s right to approve or reasonably reject any decision concerning approval, settlement or denial of any claim in accordance with the terms and conditions of such policy, contract or plan document.
Adjudication of Claims. The Committee shall have full and complete discretionary authority to make all determinations as to the right to Benefits under the Plan. In the event that a Participant believes he has not received the Benefits to which he is entitled under the Plan, a claim shall be made in writing to the Committee. The claim shall be reviewed by the Committee. If the claim is approved or denied, in full or in part, the Committee shall provide a written notice of approval or denial within 90 days with, in the case of a denial, the specific reasons for the denial and specific reference to the provisions of the Plan and/or Agreement upon which the denial is based. A claim shall be deemed denied if the Committee does not take any action within the aforesaid 90 day period. If a claim is denied or deemed denied and a review is desired, the Participant shall notify the Committee in writing within 60 days of the receipt of notice of denial or the date on which the claim is deemed to be denied, as the case may be. In requesting a review, the Participant may review the Plan or any document relating to it and submit any written issues and comments he may deem appropriate. The Committee shall then review the claim and provide a written decision within 60 days. This decision, if adverse to the Participant, shall state the specific reasons for the decision and shall include reference to specific provisions of the Plan and/or Agreement on which the decision is based. The Committee's decision on review shall be final and binding.
Adjudication of Claims. 20. THIS COURT ORDERS that if a CMI Known Creditor (other than a CMI Employee) disputes the amount of the Claim as set out in the CMI General Notice of Claim, the CMI Known Creditor shall deliver to the CMI Entities a CMI Notice of Dispute of Claim which must be received by the CMI Entities by no later than the CMI Claims Bar Date. Such Person shall specify therein whether it disputes the value of the Claim for voting and/or distribution purposes.
Adjudication of Claims. 32. THIS COURT ORDERS that the CMI Entities, with the assistance of the Monitor and on consultation with the CMI CRA, if applicable, shall review all CMI Proofs of Claim received by the CMI Claims Bar Date and shall accept, revise or reject the amount of each Claim set out therein for voting and/or distribution purposes. The CMI Entities shall by no later than 11:59 p.m. on [Filing Date plus 50 Days], 2009, notify each CMI Unknown Creditor who has delivered a CMI Proof of Claim as to whether such CMI Unknown Creditor’s Claim as set out therein has been revised or rejected for voting purposes (and for distribution purposes, if the CMI Entities (on consultation with the CMI CRA, if applicable), elect to do so), and the reasons therefor, by sending a CMI Notice of Revision or Disallowance. Where the CMI Entities do not send by such date a CMI Notice of Revision or Disallowance to a CMI Unknown Creditor, the CMI Entities shall be deemed to have accepted such CMI Unknown Creditor’s Claim in the amount set out in that CMI Unknown Creditor’s CMI Proof of Claim as a Voting Claim for voting purposes only, which shall be deemed to be that CMI Unknown Creditor’s Voting Claim.
Adjudication of Claims. BCBSNC or its designee will adjudicate Claims for Covered Prescription Drug Services electronically submitted by Network Participants through the Claims Adjudication System or manually submitted by a Member as a Paper Claim, according to the Group Health Plan, Member eligibility, and other information submitted by the Plan Administrator. In adjudicating claims, BCBSNC will rely on the information provided to it by the Plan Administrator and will not be responsible for inaccuracies in the information. Adjudication will include eligibility and coverage determination under the Group Health Plan, including the calculation of allowable costs and applicable Copayment/Deductible, or Coinsurance, payment of eligible claims, and notification of declined or ineligible Claims.
Adjudication of Claims i. Client Company authorizes DRMS to, and DRMS shall, make the initial and any administrative appeal determination with respect to each Claim (as defined in Exhibits A and B) whether such Claim is valid and payable under the terms of the applicable Coverage (as defined in Exhibits A and B).
Adjudication of Claims. (a) The City and the Union agree that Employee Health and Wellness will continue to adjudicate "Wage Continuance" claims as per current practice. This includes but is not limited to
Adjudication of Claims. The Settlement Administrator shall verify that each person who timely submits a Claim is a Settlement Class Member and shall determine whether and to what extent the Claim reflects valid Ordinary Expenses and/or Extraordinary Expenses that are reasonably traceable to the Data Security Incident, including any Claim for Time Spent. The Settlement Administrator shall determine whether a Settlement Class Member’s supporting materials are sufficient to support a Claim and the amount of such a Claim and shall use reasonable procedures to screen Claims for abuse, fraud, duplication, reimbursability through other means, or ineligibility.
Adjudication of Claims. Any claim or dispute between the parties that is not resolved in accordance with the process and procedures set forth in Schedule 3.18(b) (Dispute Resolution) shall be handled in accordance with this Section 12.13.
