Coverage decision means the approval or denial of benefits for health care services substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the terms and conditions of the health care service plan contract. A “coverage decision” does not encompass a plan or contracting provider decision regarding a Disputed Health Care Service.
Coverage decision means: ▪ An initial determination by us or our representative that results in non-coverage of a health care service; ▪ A determination by us that an individual is not eligible for coverage under the Policy; ▪ Any determination by us that results in the rescission of an individual’s coverage under the Policy. ▪ A coverage decision includes a nonpayment of all or any part of a claim. ▪ A coverage decision does not include: ♦ An adverse decision as described above; or ♦ A pharmacy inquiry.
Coverage decision means the approval or denial of health
Examples of Coverage decision in a sentence
We may also request additional information or documentation if it is reasonably necessary to make a Coverage decision concerning a claim.
You may submit a claim to Us to obtain a Coverage decision concerning whether the Plan will Cover that service.
We may request additional information or documentation if it is reasonably necessary to make a Coverage decision concerning a claim.
For example, if a pharmacy (1) does not provide You with a prescribed medication; or (2) requires You to pay for that prescription, You may submit a claim to the Plan to obtain a Coverage decision about whether it is Covered by the Plan.
Coverage decision: an initial determination by the Plan, or a representative of the Planthat results in noncoverage of a health care service.
More Definitions of Coverage decision
Coverage decision means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A “coverage decision” does not encompass a decision regarding a disputed health care item or service;
Coverage decision means a final adverse decision based on medical necessity. This definition does not include a denial of coverage for a service or treatment specifically listed in plan or evidence of coverage documents as excluded from coverage.
Coverage decision means an initial determination by Delta Dental that results in noncoverage of a Health Care Service; a determination by Delta Dental that an Enrollee is not eligible for coverage under our health benefit plan; or any determination by Delta Dental that results in the rescission of an Enrollee’s coverage under a health benefit plan. Coverage Decision includes nonpayment of all or any part of a claim.
Coverage decision means a final adverse decision
Coverage decision means a determination regarding including
Coverage decision means a final adverse decision based on medical necessity. This def- inition does not include a denial of coverage for a service or treatment specifically listed in plan or evidence of coverage documents as excluded from coverage, or a denial of coverage for a service or treatment that has already been received and for which the enrollee has no financial liability.
Coverage decision means the approval or denial of health services by {PACE Organization} substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the terms and conditions of our Enrollment Agreement with you. Credentialed refers to the requirement that all practitioners (physicians, psychologists, dentists and podiatrists) who serve {PACE Organization} participants must undergo a formal process that includes thorough background checks to verify their education, training and experience and confirm competence. Department of Health Care Services (DHCS) means the single State Department responsible for administration of the federal Medicaid Program (referred to as Medi-Cal in California), California Children Services (CCS), Genetically Handicapped Persons Program (GHPP), Child Health and Disabilities Prevention (CHDP) and other health-related programs. Disputed health care service means any health care service eligible for payment under your Enrollment Agreement with {PACE Organization} that has been denied, modified or delayed by a decision of {PACE Organization} in whole or in part due to the finding that a service is not medically necessary. A decision regarding a “disputed health care service” relates to the practice of medicine and is not a coverage decision. Eligible for nursing home care means that your health status, as evaluated by the {PACE Organization} Interdisciplinary Team, meets the State of California’s criteria for placement in either an Intermediate care facility (ICF), or a Skilled Nursing Facility (SNF). {PACE Organization’s} goal, however, is to help you to stay in the community as long as possible, even if you are eligible for nursing home care. Emergency Medical Condition and Emergency Services are defined in CHAPTER 5.