Claim Determinations Sample Clauses

Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denials. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this Contract.
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Claim Determinations. We have complete authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We shall have discretionary authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and to construe any disputed or doubtful terms under this Group Agreement, the Certificate or any other document incorporated herein. We shall be deemed to have properly exercised such authority unless We abuse our discretion by acting arbitrarily and capriciously. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claims history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing.
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Claim Determinations. We have authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We shall have authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and to construe any disputed or doubtful terms under this Group Agreement, the Certificate or any other document incorporated herein. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claims history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing. Our determinations, interpretations, and decisions on these matters are subject to de novo review by an impartial reviewer as provided in this Group Agreement or as allowed by law. Members and beneficiaries are entitled to have their claims reviewed de novo in any court with jurisdiction and to a trial by jury. AETNA HEALTH INC. (COLORADO) GROUP AGREEMENT AMENDMENT Contract Holder Group Agreement Effective Date: January 1, 2013 The Aetna Health Inc. (HMO) Group Agreement issued to the Contract Holder is hereby amended as follows: Section 5., RESPONSIBILITIES OF THE CONTRACT HOLDER, is hereby amended to include the following:
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Claim Determinations. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Certificate.
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Claim Determinations. We have responsibility to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We have the right to: determine all questions of eligibility of Members; determine the amount and type of benefits payable in accordance with the terms of this Group Agreement; and interpret the provisions of this Group Agreement, including, but not limited to, the denial of certification of the medical necessity of hospital or medical treatment. We have the right to adopt reasonable: policies; procedures; rules; and interpretations; of this Group Agreement to promote orderly and efficient administration. Our determinations, interpretations, and decisions on these matters are subject to de novo review by an impartial reviewer as provided in this Group Agreement or as allowed by law. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claim history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing. HMO IL GAAMEND-2 7-05 1 AETNA HEALTH INC. (ILLINOIS) AMENDMENT TO THE GROUP AGREEMENT TERMINATION Contract Holder Group Agreement Effective Date: January 1, 2013 The “Termination” section of the Group Agreement is hereby amended to delete section 6.3 entitled “Termination by Us”. The following replaces section 6.3:
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Claim Determinations. We have complete authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We shall have discretionary authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and to construe any disputed or doubtful terms under this Group Agreement, the Certificate or any other document incorporated herein. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claims history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing. The Member may be eligible to appeal HMO's decision through an Independent Utilization Review Organization (IURO). Please refer to the Appeal Procedure section of the Certificate for more information on this process.
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Related to Claim Determinations

  • Expert Determination If a Dispute relates to any aspect of the technology underlying the provision of the Goods and/or Services or otherwise relates to a financial technical or other aspect of a technical nature (as the Parties may agree) and the Dispute has not been resolved by discussion or mediation, then either Party may request (which request will not be unreasonably withheld or delayed) by written notice to the other that the Dispute is referred to an Expert for determination. The Expert shall be appointed by agreement in writing between the Parties, but in the event of a failure to agree within ten (10) Working Days, or if the person appointed is unable or unwilling to act, the Expert shall be appointed on the instructions of the relevant professional body. The Expert shall act on the following basis: he/she shall act as an expert and not as an arbitrator and shall act fairly and impartially; the Expert's determination shall (in the absence of a material failure to follow the agreed procedures) be final and binding on the Parties; the Expert shall decide the procedure to be followed in the determination and shall be requested to make his/her determination within thirty (30) Working Days of his appointment or as soon as reasonably practicable thereafter and the Parties shall assist and provide the documentation that the Expert requires for the purpose of the determination; any amount payable by one Party to another as a result of the Expert's determination shall be due and payable within twenty (20) Working Days of the Expert's determination being notified to the Parties; the process shall be conducted in private and shall be confidential; and the Expert shall determine how and by whom the costs of the determination, including his/her fees and expenses, are to be paid.

  • Penalty Determination H&SC section 39619.7 requires CARB to provide information on the basis for the penalties it seeks. This Agreement includes this information, which is also summarized here. The provision of law the penalty is being assessed under and why that provision is most appropriate for that violation. The penalty provision being applied, in this case, is H&SC section 42402 et seq. because TJX sold, supplied, offered for sale, or manufactured for sale consumer products for commerce in California in violation of the Consumer Products Regulations (17 CCR section 94507 et seq.). The penalty provisions of H&SC section 42402 et seq. apply to violations of the Consumer Products Regulations because the regulations were adopted under authority of H&SC section 41712, which is in Part 4 of Division 26. The manner in which the penalty amount was determined, including aggravating and mitigating factors and per unit or per vehicle basis for the penalty. H&SC section 42402 et seq. provides strict liability penalties of up to $10,000 per day for violations of the Consumer Product Regulations with each day being a separate violation. In this case, the total penalty is $196,800 for 171 days of administrative and emission violations. The penalty, in this case, was reduced because TJX made diligent efforts to cooperate with the investigation and to comply, including developing new business practices to ensure future compliance. These business practices include modifying relevant purchasing practices, delivering staff training, and implementing a vendor certification program for the relevant vendor population. Final penalties were determined based on the unique circumstances of this matter, considered together with the need to remove any economic benefit from noncompliance, the goal of deterring future violations and obtaining swift compliance, the consideration of past penalties in similar negotiated cases, and the potential cost and risk associated with litigating these particular violations. The penalty reflects violations extending over a number of days resulting in quantifiable harm to the environment considered together with the complete circumstances of this case. Penalties in future cases might be smaller or larger on a per ton basis. The final penalty, in this case, was based in part on confidential financial information or confidential business information provided by TJX that is not retained by CARB in the ordinary course of business. The penalty, in this case, was also based on confidential settlement communications between CARB and TJX that CARB does not retain in the ordinary course of business. The penalty also reflects CARB's assessment of the relative strength of its case against TJX, Inc., the desire to avoid the uncertainty, burden and expense of litigation, obtain swift compliance with the law and remove any unfair advantage that TJX may have secured from its actions. ls the penalty being assessed under a provision of law that prohibits the emission of pollution at a specified level, and, if so a quantification of excess emissions, if it is practicable to do so. The Consumer Product Regulations do not prohibit emissions above a specified level, but they do limit the concentration of VOCs in regulated products. In this case, a quantification of the excess emissions attributable to the violations was not practicable.

  • Final Determination His/her determination is final unless, within ten (10) days after notification, a recognized employee organization requests in writing to meet and confer thereon.

  • FINAL DETERMINATION BY BOARD The Board shall have the right and power to adjust and determine finally all questions as to the proper and timely performance of the work and the amounts earned under this Contract, all as provided in General Conditions.

  • Order of Benefit Determination Rules When a Member is covered by two or more plans, the rules for determining the order of benefit payments are as follows:

  • Salary Determination 12.5.1 A unit member shall receive a salary not less than the minimum salary nor more than the maximum salary (Articles 12.3 and 12.4) for the rank to which appointed, except as provided in Articles 4.15, 5.6, 10.6.1 or Article 10.6.1.1. The effective dates for salaries shall be the appropriate dates specified in Article 12.2.2.

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