Coverage Decision Sample Clauses
A Coverage Decision clause defines the process by which an insurer determines whether a particular claim or loss is covered under the terms of an insurance policy. Typically, this clause outlines the steps the insurer must take to review submitted claims, such as evaluating documentation, investigating the circumstances, and applying policy exclusions or limitations. Its core practical function is to establish a clear and fair procedure for making coverage determinations, thereby reducing disputes and ensuring that both parties understand how coverage decisions are made.
Coverage Decision. We will review the diagnosis when we receive the necessary information from the Service Contractor. If we determine that a Covered Breakdown has occurred, we will authorize a Service Contractor to proceed with the repair or replacement as provided in this Plan Agreement. Some repairs or replacements may require multiple appointments with the Service Contractor, which will be scheduled at a mutually convenient time during normal business hours. Please review “What are your obligations under this Plan Agreement” with respect to any Covered Breakdown.
Coverage Decision. Frontdoor will review the diagnosis when Frontdoor receives the necessary information from the Service Provider. If we determine that a Covered Breakdown has occurred, we will authorize a Service Provider to proceed with the repair as provided in this Plan Agreement or provide you with the Payout Amount. Some repairs may require multiple appointments with the Service Provider, which will be scheduled at a mutually convenient time during normal business hours. Please review “Your Obligations” with respect to any Covered Breakdown.
Coverage Decision. The approval or denial of health care services by HMO substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the terms and conditions of this EOC. A Coverage Decision is not an HMO decision regarding a Disputed Health Care Service.
Coverage Decision. The approval or denial of health care services by a plan, or by one of its contracting providers, substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the terms and conditions of the health care service plan contract.
Coverage Decision. An initial determination by the Health Plan or a representative of the Health Plan that results in non-coverage of a Health Care Service.
Coverage Decision. The approval or denial of health care services by a plan, or by one of its contracting providers, substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the te1ms and conditions of the health care service plan contract. The criteria used to determine whether to authorize, modify, or deny health care services are developed with the involvement from actively practicing health care providers, consistent with sound clinical principles and processes and are evaluated and updated, if necessary, at least annually. These criteria are available to the public upon request. The materials provided to enrollees are guidelines used by the Plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under this contract. Upon enrollee request, ▇▇▇▇▇▇ will disclose its processes, including criteria and guidelines, for authorizing, modifying or denying services.
Coverage Decision. An initial determination by the Health Plan or a representative of the Health Plan that results in non-coverage of a Health Care Service. Coverage Decision includes: a determination by a Health Plan that an individual is not eligible for coverage under the Health Plan’s health benefit plan; any determination by the Health Plan that results in the rescission of an individual's coverage under a health benefit plan; or nonpayment of all or any part of a claim. A Coverage Decision does not include an Adverse Decision. Dependent: A Member whose relationship to a Subscriber is the basis for membership eligibility and who meets the eligibility requirements as a Dependent (for Dependent eligibility requirements see “Who Is Eligible” in Section 1: Introduction).