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.
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.
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.
Examples of Claims Adjudication in a sentence
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. 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.
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 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
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.