Benefits Determination definition

Benefits Determination as those terms are defined in the most recent version of the Trusted Exchange Framework and Common Agreement as published in the Federal Register. Prior to publication of the Trusted Exchange Framework and Common Agreement in the Federal Register, those terms shall have the meaning set forth in the Draft Trusted Exchange Framework published by the Office of the National Coordinator for Health Information Technology on January 5, 2018.
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Benefits Determination means a determination made by any federal or state agency as to whether an individual qualifies for federal or state benefits for any purpose other than health care (for example, Social Security disability benefits) to the extent permitted or required by Applicable Law. Disclosure of PHI for this purpose may require an Authorization if the conditions of 45 C.F.R. part 154.512(k)(6) are not met.
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Examples of Benefits Determination in a sentence

  • In the absence of a birth certificate, an elderly applicant may substitute a Social Security Benefits Determination document for the birth certificate.

  • External ReviewStandard External Review: If the claimant has exhausted internal appeal reviews, an external review by an Independent Review Organization (IRO) may be requested for review of an Adverse Benefit Determination or Final Internal Adverse Benefits Determination which was based on a judgment as to the Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of the health care Service or treatment.

  • This section applies when This Plan is the Secondary Plan in accordance with the Order of Benefits Determination Rules outlined above.

  • For all Prospective, Concurrent and Retrospective Assessments of a Non-Administrative Adverse Benefits Determination, the notice shall be made as soon as practical considering medical circumstances, but in no case later than 30 calendar days after the Company’s receipt of the request for review.

  • If the Order of Benefits Determination provisions of the Other Plan do not agree under these circumstances with the Order of Benefit Determination provisions of this benefit program, this rule will not apply.

  • Order of Benefits Determination RulesWhen a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:(a) The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan.

  • You will not be charged any fees if the Bank declines to authorize a debit card payment transaction or ATM withdrawal.

  • If the Orderof Benefits Determination provisions of the Other Plan do not agree under these circumstances with the Order of Benefit Determination provisions of this benefit program, this rule will not apply.

  • If You are known to have group coverage through any other health plan or insurer, responsibility for payment of benefits is determined by following the Rules Establishing the Order of Benefits Determination, formulated by the Insurance Commissioner of the State of California and incorporated in this Certificate.

  • The individual who decides the appeal will not have been involved in the previous Adverse Benefits Determination with respect to the claim.

Related to Benefits Determination

  • Administrative merits determination means certain notices or findings of labor law violations issued by an enforcement agency following an investigation. An administrative merits determination may be final or be subject to appeal or further review. To determine whether a particular notice or finding is covered by this definition, it is necessary to consult section II.B. in the DOL Guidance.

  • Expert Determination the process described in Paragraph 6 of Schedule 8.3 (Dispute Resolution Procedure);

  • Adverse Benefit Determination means any of the following:

  • Eligibility Determination means an approval or denial of eligibility and a renewal or termination of eligibility as set forth in OAR 410-200-0015;¶

  • Claim Determination Period means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

  • Self-Determination means a philosophy and process by which individuals with developmental disabilities are empowered to gain control over the selection of support services that meet their needs. The basic principles of self-determination are:

  • Event Determination Date means either:

  • SOFR Determination Date has the meaning specified in the definition of “Daily Simple SOFR”.

  • Payment Determination Date means, with respect to any Payment Date, one (1) Business Day immediately preceding such Payment Date.

  • Disability benefit recipient means a member who is receiving a disability benefit.

  • Standard of Conduct Determination shall have the meaning ascribed to it in Section 9(b) below.

  • Final Determination Date means the following:

  • TIA Applicability Determination As defined in Section 12.12.

  • Disability benefits means any cash payments which are payable to a covered individual for all or part of a period of disability pursuant to P.L.1948, c.110 (C.43:21-25 et al.).

  • Interest Determination Date means, with respect to a Rate of Interest and Interest Accrual Period, the date specified as such hereon or, if none is so specified, (i) the first day of such Interest Accrual Period if the Specified Currency is Sterling or (ii) the day falling two Business Days in London for the Specified Currency prior to the first day of such Interest Accrual Period if the Specified Currency is neither Sterling nor euro or (iii) the day falling two TARGET Business Days prior to the first day of such Interest Accrual Period if the Specified Currency is euro.

  • SOFR Determination Time means 3:00 p.m. (New York time) on the U.S. Government Securities Business Day, at which time Compounded SOFR is published on the FRBNY’s Website.

  • Monthly Report Determination Date The meaning specified in Section 10.7(a).

  • Final Determination means the final resolution of liability for any Tax for any taxable period, by or as a result of (a) a final decision, judgment, decree or other order by any court of competent jurisdiction that can no longer be appealed, (b) a final settlement with the IRS, a closing agreement or accepted offer in compromise under Sections 7121 or 7122 of the Code, or a comparable agreement under the Laws of other jurisdictions, which resolves the entire Tax liability for any taxable period, (c) any allowance of a refund or credit in respect of an overpayment of Tax, but only after the expiration of all periods during which such refund or credit may be recovered by the jurisdiction imposing the Tax, or (d) any other final resolution, including by reason of the expiration of the applicable statute of limitations or the execution of a pre-filing agreement with the IRS or other Taxing Authority.

  • Initial determination means the first child custody determination concerning a particular child.

  • Final Adverse Benefit Determination means an adverse benefit determination that is upheld at the completion of a health plan issuer’s internal appeals process.

  • Claim for Benefits means a request for a Plan benefit or benefits made by a Member in accordance with the Plan’s Appeals Procedures, including any Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests for benefit payment).

  • Index Determination Date means, in relation to any Index, a date on which such Indexfalls to be determined in accordance with the Conditions;

  • Reset Determination Date means, in respect of the First Reset Period, the second Business Day prior to the First Reset Date and, in respect of each Subsequent Reset Period thereafter, the second Business Day prior to the first day of each such Subsequent Reset Period;

  • Distribution Determination Date means, in respect of any Distribution Period, that number of business days prior thereto as is set out in the applicable Pricing Supplement or on the face of the relevant Perpetual Security;

  • LIBOR Determination Date With respect to any Interest Accrual Period for the LIBOR Certificates, the second London Business Day preceding the commencement of such Interest Accrual Period.

  • Retirement Benefits means benefits paid by reference to reaching, or the expectation of reaching, retirement or, where they are supplementary to those benefits and provided on an ancillary basis, in the form of payments on death, disability, or cessation of employment or in the form of support payments or services in case of sickness, indigence or death. In order to facilitate financial security in retirement, these benefits may take the form of payments for life, payments made for a temporary period, a lump sum, or any combination thereof;