Common use of Claim Review Clause in Contracts

Claim Review. ‌ A claim review may be done only when a PARTICIPANT requests a review of denied BENEFITS. When a claim review has been completed, and the decision is to uphold the denial of BENEFITS, the PARTICIPANT shall receive written notification as to the specific reason(s) for the continued denial of BENEFITS and of his/her right to file a grievance. A CASE REVIEW OR CLAIM REVIEW MAY NOT BE SUBSTITUTED FOR A GRIEVANCE. GRIEVANCES REGARDING NONCOVERED SERVICES OR SERVICES EXCLUDED FROM COVERAGE BY THE HEALTH BENEFIT PLAN SHALL BE HANDLED LIKE ANY OTHER GRIEVANCE. GRIEVANCES SUBMITTED BY A HEALTH CARE PROVIDER CANNOT BE REFERRED TO THE CLAIM APPEAL UNIT.

Claim Review. ‌ A claim review may be done only when a PARTICIPANT requests a review of denied BENEFITS. When a claim review has been completed, and the decision is to uphold the denial of BENEFITS, the PARTICIPANT shall receive written notification as to the specific reason(s) for the continued denial of BENEFITS and of his/her right to file a grievance. A CASE REVIEW OR CLAIM REVIEW MAY NOT BE SUBSTITUTED FOR A GRIEVANCE. GRIEVANCES REGARDING NONCOVERED SERVICES OR SERVICES EXCLUDED FROM COVERAGE from coverage BY THE HEALTH BENEFIT PLAN SHALL BE HANDLED LIKE ANY OTHER GRIEVANCE. GRIEVANCES SUBMITTED BY A HEALTH CARE health care PROVIDER CANNOT BE REFERRED TO THE CLAIM APPEAL UNIT.