Coverage determination definition

Coverage determination means a determination of the
Coverage determination means a determination of the circumstances, if any, under which a health technology will be included as a covered benefit in a state purchased health care program.
Coverage determination means a determination of the circumstances, if any, under which a health technology will be included as a covered benefit in a state purchased health care program, as set forth in RCW 70.14.080, as amended.

Examples of Coverage determination in a sentence

  • A decision with respect to a request for determination of insured status, a notice of unemployment, or a claim for benefits.b. Coverage determination.

  • Coverage determination reviews may include requests to cover non-preferred drugs, obtain Preauthorization for a specific drug, or exceptions to other utilization management requirements, such as quantity limits.

  • Coverage determination and redeterminations are the delegated to the PBM.

  • Costs (copayments, coinsurance,deductibles, and premiums)Extra Help paying for Part D 83–85Help with Part A and Part B costs 86–87 Medicare Advantage Plans 60Original Medicare 52–53Part A and Part B 21–24, 26–49Part D late enrollment penalty 77–79 Coverage determination (Part D) 91–92 Covered services (Part A and Part B) 25–49 Creditable prescription drug coverage 73,75, 77–79, 81, 85, 113Custodial care 25, 50, 114 Note: The page numbers shown in bold provide the most detailed information.

  • SAMPLEExperimental, Investigational or Unproven - Services, treatments, supplies, drugs, devices, or procedures determined by PHP to be any one or more of the following at the time a Coverage determination for any particular case is made:A.

  • Coverage determination: Claims are subject to dental necessity verification and availability of dental benefits when they are processed, as well as the terms and conditions of the applicable BCBSM certificates and riders.

  • Coverage determination is not made solely on the basis of general inferences about patients with similar diagnoses or on data related to utilization generally but is based upon objective clinical evidence regarding the beneficiary's individual need for care (42 CFR§ 409.44(a)).

  • Coverage determination recommendation is made through Utilization Review or EPSDT committees on a case by case basis when there is evidence-based efficacy research and documentation of member medical necessity.

  • See Medicare Cost Plans.Costs (copayments, coinsurance, deductibles, and premiums)Extra Help paying for Part D 97–99Help with Part A and Part B costs 99–100 Medicare Advantage Plans 70Original Medicare 63–64Part A and Part B 26–29, 30–59Part D late enrollment penalty 89–91 Coverage determination (Part D) 106–107 Coverage gap 88, 98Covered services (Part A and Part B) 29–59 Note: The page numbers shown in bold provide the most detailed information.

  • Coverage determination is not made solely on the basis of general inferences about patients with similar diagnoses or on data related to utilization generally but is based upon objective clinical evidence regarding the beneficiary’s individual need for care(42 CFR § 409.44(a)).


More Definitions of Coverage determination

Coverage determination means a determination of a Relevant Minister under Chapter 3 Part 1 Division 1 of the National Gas Law; Covered Pipeline means a pipeline:
Coverage determination as defined in RCW 70.14.080 means a determination of the circumstances, if any, under which a health tech- nology will be included as a covered benefit in a state purchased health care program.
Coverage determination means a determination of a relevant Minister under Chapter 3 Part 1 Division 1; "coverage recommendation" means a recommendation of the NCC under Chapter 3 Part 1 Division 1; "coverage revocation determination" means a determination of a relevant Minister under Chapter 3 Part 1 Division 2; "coverage revocation recommendation" means a recommendation of the NCC under Chapter 3 Part 1 Division 2; "covered pipeline" means a pipeline--
Coverage determination as defined in RCW 70.14.- 080 means a determination of the circumstances, if any, under which a health technology will be included as a cov- ered benefit in a state purchased health care program((, as set forth in RCW 70.14.080, as amended)).
Coverage determination means with respect to items and services for which coverage may be provided under a health plan, a de- termination of whether or not such items and services are covered or reimbursable under the coverage and terms of the con- tract.
Coverage determination. ’ means a determination by

Related to Coverage determination

  • Adverse determination shall have the meaning set forth in Section 19.7.

  • 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:

  • Adverse Benefit Determination means any of the following:

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

  • Rate Determination Date means two (2) Business Days prior to the commencement of such Interest Period (or such other day as is generally treated as the rate fixing day by market practice in such interbank market, as determined by the Administrative Agent; provided that to the extent such market practice is not administratively feasible for the Administrative Agent, such other day as otherwise reasonably determined by the Administrative Agent).

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

  • Final Determination Date means the following:

  • TIA Applicability Determination As defined in Section 12.12.

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

  • Extension Determination Date means, in respect of a Series of Covered Bonds, the date falling two Business Days after the expiry of seven days from (and including) the Final Maturity Date of such Covered Bonds.

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

  • Rate Determination Notice has the meaning specified in Section 3.07(g).

  • 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;

  • Flood Elevation Determination means a determination by the Administrator of the water surface elevations of the base flood, that is, the flood level that has a one percent or greater chance of occurrence in any given year.

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

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

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

  • Final Adverse Determination means an Adverse Determination involving a Covered Service that has been upheld by Blue Cross and Blue Shield or its designated utilization review organization, at the completion of Blue Cross and Blue Shield's internal grievance process procedures.

  • Reference Rate Determination Date means, in relation to any Reference Rate Business Day(i):

  • Child custody determination means a judgment, decree, or other order of a court providing for the legal custody, physical custody, or visitation with respect to a child. The term includes a permanent, temporary, initial, and modification order. The term does not include an order relating to child support or other monetary obligation of an individual.

  • 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.

  • 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.

  • 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.

  • Screen Rate Determination is specified in the applicable Final Terms as the manner in which the Rate of Interest is to be determined and the Reference Rate specified in the applicable Final Terms is not XXXXX or SOFR, the Rate of Interest for each Interest Period will, subject as provided below, be either: