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 determination regarding including
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 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 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 care services by a health plan, or by one of its contracting entities, 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 contract. A coverage decision does not encompass a health plan or contracting provider decision regarding a disputed health care service.