Noncertification definition

Noncertification means a determination by an insurer or its designated

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Noncertification means a Noncertification. – A determination by an insurer

Noncertification means a determination by an insurer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or does not meet the prudent layperson standard for coverage of emergency services in G.S. 58-3-190, and the requested service is therefore denied, reduced, or terminated. A "noncertification" is not a decision rendered solely on the basis that the health benefit plan does not provide benefits for the health care service in question, if the exclusion of the specific service requested is clearly stated in the certificate of coverage. A "noncertification" includes any situation in which an insurer or its designated agent makes a decision about a covered person's condition to determine whether a requested treatment is experimental, investigational, or cosmetic, and the extent of coverage under the health benefit plan is affected by that decision.

Examples of Noncertification in a sentence

• Non-certification decisions are not subject to the grievance procedure.

• You may not file a subsequent request for an external review involving the same Non-certification Decision for which You have already received an external review decision.

• Non-certification decisions are not subject to the 24 grievance procedure.

• Non-certification decisions are not subject to grievance/arbitration set forth in Article 14.

• Any additional Deductible incurred by you as a penalty for receiving non-certified services or expenses incurred under the Prescription Drug benefit, another supple- mental benefit or any Noncertification Deductibles, are not applied to your Deductible.

• Non-certification decisions are not subject to grievance/arbitration set forth in Article XX.

• Non-certification is defined as failing to gain non-probationary status.

• No Deductible $1,500 Noncertification Deductible ...............................................................................

• Expedited Noncertification Appeals • An expedited review process is available to address those situations where the standard appeal time frames would reasonably appear to seriously jeopardize life or health, or jeopardize the ability to regain maximum function.

• Non-certification During Probationary Period ...................................................

More Definitions of Noncertification

Noncertification means a Noncertification. – A determination by an insurer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care healthcare service has been reviewed and, based upon the information provided, does not meet the insurer's requirements for medical necessity, appropriateness, health care healthcare setting, level of care care, or effectiveness, or does not meet the prudent layperson standard for coverage of emergency services in

Noncertification means a determination by an insurer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, does not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or does not meet the prudent layperson standard for coverage of emergency services in G.S. 58-3-190, and the requested service is therefore denied, reduced, or

Noncertification is a determination by an HMO or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and based upon the information provided, does not meet the HMO’s requirements for Medical Necessity, appropriateness, health care setting, level of care or effectiveness and the requested service is therefore denied, reduced or terminated. A noncertification is not a decision rendered solely on the basis that the HMO does not provide benefits for the health care service in question, if the exclusion of the specific service requested is clearly stated in the certificate of coverage.