Claims Adjudication definition

Claims Adjudication means Contractor’s final decision to pay claims submitted or deny them after comparing claims to the benefit or coverage requirements.
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Claims Adjudication means processing of electronic claims for prescriptions which includes full compliance with 340B Patient eligibility requirements, which include but are not limited to: verifying Patient and provider eligibility and formulary status of prescribed medication. The electronic claims adjudication process shall include a real time Lower of Pricing analysis to verify the lowest cost alternative for the specific claim, communicated back to the CPN at the time of claims adjudication.
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Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant to the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or Member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any Copayment/Deductible or Coinsurance payable by a Member, as well as drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof.
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Examples of Claims Adjudication in a sentence

  • If the employee disputes the decision, the employee may request to have the claim reviewed by a claims review committee comprised of three independent and qualified medical doctors agreed to by the Claims Adjudication Committee.

  • SIGNED BY:Drew Lafond and Alisa LombardCounsel for the Intervener, the Indigenous Bar Association 30 Alisa Lombard, "Specific Claims Adjudication Processes and Cultural Diversity: Reconciling Societal Traditions" (2016) 29 Can J Admin L & Prac 187 at 204; John Barrows, "With or Without You: First Nations Law (in Canada)" (1996) 41 McGill LJ 629 at 655.

  • Prime will process Claims for Prescription Drugs Products and Services electronically submitted by Network Participants through the Claims Adjudication System, according to Benefit Plan benefit and eligibility information submitted by Claim Administrator to Prime and will pay eligible Claims and provide to the submitting entity electronic notification of declined or ineligible Claims.


More Definitions of Claims Adjudication

Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or Member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any Copayment/Deductible or Coinsurance payable by a Member, as well as concurrent (on-line at point of service) Drug Utilization Review.
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Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a
Sample 1
Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a member, as well as concurrent (on- line at point of service) drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof. The cost to the Employer and the Member will be the lesser of the MAC price, the Ingredient Cost, the Usual and Customary price, or the cash price.
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Related to Claims Adjudication

  • Third party claimant means any individual, corporation, association, partnership, or other legal entity asserting a claim against any individual, corporation, association, partnership, or other legal entity insured under an insurance policy or insurance contract.

  • Adjudicatory hearing means a hearing to determine:

  • Claim Form or “Proof of Claim Form” means the form, substantially in the form attached hereto as Exhibit 2 to Exhibit A, that a Claimant or Settlement Class Member must complete and submit should that Claimant or Settlement Class Member seek to share in a distribution of the Net Settlement Fund.

  • Appeal means a request for a review of the Floodplain Administrator's interpretation of any provision of this ordinance.

  • Claimant means a person who believes that he or she is being denied a benefit to which he or she is entitled hereunder.

  • Claim means any action, claim, obligation, liability, expense, lawsuit, demand, suit, inquiry, hearing, investigation, notice of a violation, litigation, proceeding, arbitration, or other dispute, whether civil, criminal, administrative or otherwise, whether pursuant to contractual obligations or otherwise.

  • Claims Bar Date means the applicable bar date by which Proofs of Claim must be Filed, as established by: (a) the Bar Date Order; (b) a Final Order of the Bankruptcy Court; or (c) the Plan.

  • Claimants means any Persons who have submitted a Claim to the Receiver or to the Joint Liquidators.

  • Claims Objection Bar Date means the deadline for objecting to a Claim, which shall be on the date that is the later of (a) 180 days after the Effective Date and (b) such other period of limitation as may be specifically fixed by the Debtors or the Reorganized Debtors, as applicable, or by an order of the Bankruptcy Court for objecting to Claims.

  • Fraud Claim means any claim based in whole or in part upon fraud, willful misconduct or intentional misrepresentation.

  • Adverse Benefit Determination means any of the following:

  • Third Party Claim has the meaning set forth in Section 7.05(a).

  • Claims Administration means the processing of claims made under the Shared Policies, including the reporting of claims to the insurance carriers, management and defense of claims and providing for appropriate releases upon settlement of claims.

  • Claims Administrator means the firm proposed by Class Counsel and appointed by the Courts to administer the Settlement Amount in accordance with the provisions of this Settlement Agreement and the Distribution Protocol, and any employees of such firm.

  • First party claimant means an individual, corporation, association, partnership or other legal entity asserting a right to payment under an insurance policy or insurance contract arising out of the occurrence of the contingency or loss covered by such policy or contract;

  • Denial means the process of refusing to grant a license after OCCL receives an application. This constitutes refusal of permission to operate.

  • Appeals Panel means a panel appointed by the Chief Compliance Officer pursuant to Rule 620.

  • Proof of Claim and Release means the Proof of Claim and Release form for submitting a Claim, which, subject to approval of the Court, shall be substantially in the form attached hereto as Exhibit A-2, that a Class Member must complete and submit should that Class Member seek to share in a distribution of the Net Settlement Fund.