Disputed Health Care Service definition

Disputed Health Care Service means any health care service eligible for coverage and payment under a health care service plan contract that has been denied, modified, or delayed by a decision of the plan, or by one of its contracting providers, in whole or in part due to a finding that the service is not Medically Necessary.
Sample 1Sample 2Sample 3
Disputed Health Care Service means any health care service eligible for coverage and payment that has been denied, modified or delayed by a decision of the insurer or by one of its contracting providers, in whole or in part due to a finding that the service was not medically necessary. A decision regarding a disputed health care service relates to the practice of medicine and is not a coverage decision.
Sample 1Sample 2
Disputed Health Care Service means any health care service eligible for coverage and payment under the Policy that has been denied, modified, or delayed by a decision by Us, in whole or in part due to a finding that the service is not Medically Necessary.
Sample 1

Examples of Disputed Health Care Service in a sentence

  • A written reconsideration decision will be provided; and• If you still remain dissatisfied with the reconsideration decision following review by Health Net, you may request an independent review or go through the binding arbitration remedy set forth in the "Independent Medical Review of Grievances Involving a Disputed Health Care Service" and "Binding Arbitration" provisions of the "General Provisions" section of this EOC.

  • If the IMR determines the service is Medically Necessary, Health Net will provide the Disputed Health Care Service.

  • It does not include a plan or contracting provider decision regarding a Disputed Health Care Service.

  • If the Member receives a decision by the Director of the Department that a Disputed Health Care Service is Medically Necessary, Health Plan will promptly implement the decision.In the case of reimbursement for services already provided, Health Plan will reimburse the provider or Member within five (5) working days.

  • A block cipher is considered “chosen-ciphertext” secure when SecjE (q, t) is suffi-ciently small.˜Similarly, we define Secj (q, t) as the maximum advantage an adversary canEobtain when trying to distinguish EK(·, ·), DK(·, ·) from Π, Π˜ ˜ ˜˜−1˜E, when given qqueries and t time.

  • The request for an Administrative Review must be submitted in writing to CalPERS within thirty(30) days from the date of the DMHC FABD or, the IMR determination letter, in cases involving a Disputed Health Care Service, or Experimental or Investigational determination.

  • Disputed Health Care Service - any Health Care Service eligible for coverage and payment under your Blue Shield Plan that has been denied, modified or delayed by Blue Shield or one of its contracting providers, in whole or in part because the service is deemed not Medically Necessary.

  • The Member will receive written notice of an adverse benefit determination (including Coverage Decisions and Disputed Health Care Service decisions) from the HMO.

  • Disputed Health Care Service grievances: A disputed health care service grievance concerns any heath care service eligible for coverage and payment under this Evidence of Coverage booklet that has been denied, modified, or delayed in whole or in part due to a finding that the service is not medically necessary.

  • The complaint and appeals process, including independent medical review from the California Department of Insurance, is described in the "Grievance and Appeals Process" and "Independent Medical Review of Grievances Involving a Disputed Health Care Service " sections of this Policy.

Related to Disputed Health Care Service

  • Health care service means that service offered or provided

  • Home health care services means medical and nonmedical services, provided to ill, disabled or infirm persons in their residences. Such services may include homemaker services, assistance with activities of daily living and respite care services.

  • Health care services means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

  • Managed health care system means: (a) Any health care

  • Licensed health care provider means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board.

  • Licensed health care professional means a person who possesses a professional medical license that is valid in Oregon. Examples include, but are not limited to, a registered nurse (RN), nurse practitioner (NP), licensed practical nurse (LPN), medical doctor (MD), osteopathic physician (DO), respiratory therapist (RT), physical therapist (PT), physician assistant (PA), or occupational therapist (OT).

  • Health care decision means any decision regarding the health care of the prospective donor.

  • COVERED HEALTHCARE SERVICES means any service, treatment, procedure, facility, equipment, drug, device, or supply that we have reviewed and determined is eligible for reimbursement under this plan.

  • Health care provider or "provider" means:

  • Health care system means any public or private entity whose function or purpose is the management of, processing of, enrollment of individuals for or payment for, in full or in part, health care services or health care data or health care information for its participants;

  • Basic health care services means in and out-of-area emergency services, inpatient hospital and

  • Federal Health Care Program has the meaning set forth in 42 U.S.C. 1320a-7b(f).

  • Indian Health Care Provider means a health care program operated by the Indian Health Service (IHS) or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (otherwise known as an I/T/U) as those terms are defined in § 4 of the Indian Health Care Improvement Act (25 USC § 1603). Indian Health Care Provider includes a 638 Facility and provision of Indian Health Service Contract Health Services (IHS CHS).

  • Health care plan means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

  • Licensed health care practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the Secretary of the Treasury.

  • Health care professional means a physician or other health care practitioner licensed, accredited or certified to perform specified health care services consistent with state law.

  • PREVENTIVE CARE SERVICES means covered healthcare services performed to prevent the occurrence of disease as defined by the Affordable Care Act (ACA). See Preventive Care and Early Detection Services in Section 3. PRIMARY CARE PROVIDER (PCP) means, for the purpose of this plan, professional providers that are family practitioners, internists, and pediatricians. For the purpose of this plan, gynecologists, obstetricians, nurse practitioners, and physician assistants may be credentialed as PCPs. To find a PCP or check that your provider is a PCP, please use the “Find a Doctor” tool on our website or call Customer Service.

  • Home Health Care Agency means an agency or organization which provides a program of home health care and which:

  • Child care services means the range of activities and programs provided by a certificate holder to an enrolled child, including personal care, supervision, education, guidance, and transportation.

  • Advance health care directive means a power of attorney for health care or a record signed or authorized by a prospective donor containing the prospective donor’s direction concerning a health care decision for the prospective donor.

  • Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Health care practitioner means an individual licensed

  • Health Care Operations shall have the meaning given to such term under the HIPAA 2 Privacy Rule in 45 CFR § 164.501.

  • Health care entity means any health care provider, health plan or health care clearinghouse.

  • Health carrier or "carrier" means a disability insurer

  • Community mental health program means all mental health