Benefit determination definition
Benefit determination means a decision of the enrollee's entitlement to payment for
Benefit determination means a decision to approve or deny a request to provide or make payment for a health care service or treatment.
Benefit determination means a decision to approve or deny a request to provide or
Examples of Benefit determination in a sentence
Each Clinical Peer selected pursuant will review and consider all of the information and documents considered by The Plan in making the adverse benefit determination or the final internal Benefit determination and any other information submitted in writing by the Member or the Member’s authorized representative.
More Definitions of Benefit determination
Benefit determination means a decision by an MCO about a request for services (also referred to as “prior authorizations” or “medical necessity reviews”).
Benefit determination means a determination by the Plan Administrator on a claim for benefits under the Plan, whether or not an Adverse Benefit Determination.
Benefit determination means a decision of the enrollee's entitlement to payment for covered health care services as defined in an agreement with the payor or its delegate.
Benefit determination means a notification, in writing, approved by the Tribal Health Services Professionals, issued by the Program Administrator to the applicant (or his or her Financial Conservator), that indicates a finding of approval or denial of his or her application for Disability Income Benefits and/or addresses a Participant's Continued Qualification for the Program, wherein Disability Income Benefits may be continued, suspended or terminated.
Benefit determination means any of the following:
1. The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.
2. The reduction, suspension, or termination of a previously authorized service.
3. The denial, in whole or in part, of payment for a service.
4. The failure to provide services in a timely manner.
5. The failure of the PAHP to act within the timeframes provided in §438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals.
6. For a resident of an area with only on PAHP, the denial of an enrollee's request to exercise his or her right, under §438.52(b)(2)(ii), to obtain services outside the network.
7. The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.
Benefit determination means a decision involving any issue related to a claimant's qualification or eligibility for benefits, including monetary, nonmonetary, and separation issues. The term also includes a claimant's overpayment amount and determinations regarding waiver of overpayment recovery.
Benefit determination means a notification, in writing, approved by the Tribal Health Services Professionals, issued by the Program Administrator to the applicant (or their Financial Conservator or Power of Attorney), that indicates a finding of approval or denial of their application for Disability Benefits and/or addresses a Participant’s Continued Qualification for the Program, wherein Disability Benefit may be continued, suspended or terminated.