Common use of Coverage Determinations Clause in Contracts

Coverage Determinations. If Tailored Plan or its authorized representative determines that services, supplies, or other items are covered under its health benefit plan or dental plan, including any determination under G.S. 58-50-61 or the Tailored Plan Contract, as applicable, Tailored Plan shall not subsequently retract its determination after the services, supplies, or other items have been provided, or reduce payments for a service, supply, or other item furnished in reliance on such a determination, unless the determination was based on a material misrepresentation about the Covered Person’s health condition that was knowingly made by the Covered Person or Provider. (Section VII. Attachment G.1.1(bb)(i) p 82; G. S. 58-3-200(c) (to the extent applicable))