Claims Determinations. If a claim for a plan benefit is denied or disregarded, in whole or in part, participants have the right to know why this was done, to obtain copies of documents relating to the decision without charge and to appeal any denial within certain time schedules.
Claims Determinations. Defendant shall calculate the amount of the Claims Settlement Payment, if any, to which each Class Member who timely submits a Claim Form is entitled. After Defendant has calculated amounts owed to Class Members, Defendant shall confirm through a collective declaration to be provided to Class Counsel, from an employee with knowledge, that Defendant calculated amounts owed to Class Members in accordance with the terms and conditions of the Settlement Agreement, and that the calculations were undertaken in good faith and are accurate to the best of the declarant’s knowledge.
Claims Determinations. Within 30 days of Our receipt of a claim, We will notify You of the action We have taken on it. However, this 30-day period may be extended by an additional 15 days in the following situations: When We cannot take action on the claim due to circumstances beyond Our control, We will notify You within the initial 30-day period that an extension is necessary. This notification includes an explanation of why the extension is necessary and when We expect to act on the claim. When We cannot take action on the claim due to lack of information, We will notify You within the initial 30-day period that the extension is necessary. This notification includes a specific description of the additional information needed and an explanation of why it is needed. We must allow You at least 45 days to provide Us with the additional information if We are seeking it from You. If We do not receive the requested information to process the claim within the time We have allowed, We will deny the claim. OUT-OF-AREA SERVICES We have a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as "Inter-Plan Programs." Whenever You obtain health care services outside of Our service area, the claims for these services may be processed through one of these Inter-Plan Programs, which include the BlueCard Program and may include negotiated National Account arrangements available between Us and other Blue Cross and Blue Shield Licensees. Typically, when accessing care outside Our service area, You will obtain care from health care Providers that have a contractual agreement (i.e., are "participating Providers") with the local Blue Cross and/or Blue Shield Licensee in that other geographic area ("Host Blue"). In some instances, You may obtain care from nonparticipating Providers. Our payment practices in both instances are described below. BlueCard Program Under the BlueCard Program, when You access Covered Services within the geographic area served by a Host Blue, We will remain responsible for fulfilling Our contractual obligations. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating Providers. Whenever You access Covered Services outside Our service area and the claim is processed through the BlueCard Program, the amount You pay for Covered Services is calculated based on the lower of: The billed covered charges for Your Covered Services; or The negotiated price that the Host Blue...
Claims Determinations. For purposes of this Settlement only, the Defendant shall calculate the amount of the Non-Material Depreciation and General Contractor Overhead and Profit Depreciation (if any) to be used in determining the Settlement Payment amounts for each claim in Groups A, B, C, and D (from Section 6.4) as follows, subject to the provisions set forth in Section 7.2:
Claims Determinations. Beginning 30 days after posting of Class Notices and on a rolling basis periodically thereafter, the Defendants, or outside contract counsel retained by and under the control of Defendants, shall calculate the amount of the Claims Settlement Payment, if any, to which each Class Member who timely submits a Claim Form is entitled, based on information that includes but not limited to:
Claims Determinations. The settlement administrator shall pay 112.5% of outstanding “Labor Depreciation” to all class members who fall within Sections 4.1.1 / 6.4. The settlement administrator shall pay the respective percentages that apply to the withheld “Labor Depreciation” to all class members who fall within Sections 4.1.2 / 6.5.
