Claims Adjudication definition

Claims Adjudication means Contractor’s final decision to pay claims submitted or deny them after comparing claims to the benefit or coverage requirements.
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Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant to the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or Member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any Copayment/Deductible or Coinsurance payable by a Member, as well as drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof.
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Claims Adjudication means processing of electronic claims for prescriptions which includes full compliance with 340B Patient eligibility requirements, which include but are not limited to: verifying Patient and provider eligibility and formulary status of prescribed medication. The electronic claims adjudication process shall include a real time Lower of Pricing analysis to verify the lowest cost alternative for the specific claim, communicated back to the CPN at the time of claims adjudication.
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Examples of Claims Adjudication in a sentence

  • If the employee disputes the decision, the employee may request to have the claim reviewed by a claims review committee comprised of three independent and qualified medical doctors agreed to by the Claims Adjudication Committee.

  • III-2Timeliness of Claims Adjudication by the MCOs ....................................................................

  • Notice of Commencement of Iraq Claims Adjudication Program, and of Program Completion Date, 78 Fed.

  • III-24Provider Education Related to Claims Adjudication ................................................................

  • There are almost identical provisions in section 24 of the Minor Employment Claims Adjudication Board Ordinance (Cap 453) and section 21 of the Small Claims Ordinance (Cap 338).

  • Prime will process Claims for Prescription Drugs Products and Services electronically submitted by Network Participants through the Claims Adjudication System, according to Benefit Plan benefit and eligibility information submitted by Claim Administrator to Prime and will pay eligible Claims and provide to the submitting entity electronic notification of declined or ineligible Claims.

  • The Claims Adjudication date is the date of Contractor’s payment or denial.

  • Certification from the Insurance Commission that it has a reputable claims settlement record with the Claims Adjudication Division within the last six (6) months prior to bid opening, if the insurance/reinsurance company is a domestic corporation.

  • Claims Adjudication and Payment (25 points) Adjustments have been made so that the last sentence would now read: In particular, the Contractor shall pay at least ninety percent (90%) of all “clean claims” from NEMT Providers within thirty (15) days following receipt.

  • The Expedited Claims Adjudication Initiative is a pilot pro- gram designed to streamline the claims adjudication and appeals process.


More Definitions of Claims Adjudication

Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a
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Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or Member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any Copayment/Deductible or Coinsurance payable by a Member, as well as concurrent (on-line at point of service) Drug Utilization Review.
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Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a member, as well as concurrent (on- line at point of service) drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof. The cost to the Employer and the Member will be the lesser of the MAC price, the Ingredient Cost, the Usual and Customary price, or the cash price.
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Related to Claims Adjudication

  • Final Adjudication has the meaning set forth in Section 5.5.

  • Third party claimant means any individual, corporation, association, partnership, or other legal entity asserting a claim against any individual, corporation, association, partnership, or other legal entity insured under an insurance policy or insurance contract.

  • Adjudicatory hearing means a hearing to determine:

  • Claim Form or “Proof of Claim Form” means the form, substantially in the form attached hereto as Exhibit 2 to Exhibit A, that a Claimant or Settlement Class Member must complete and submit should that Claimant or Settlement Class Member seek to share in a distribution of the Net Settlement Fund.

  • Appeal means a request for a review of the Floodplain Administrator's interpretation of any provision of this ordinance.

  • Claimant means a person or entity who or which submits a Claim Form to the Claims Administrator seeking to be eligible to share in the proceeds of the Settlement Fund.

  • Claim means any action, claim, obligation, liability, expense, lawsuit, demand, suit, inquiry, hearing, investigation, notice of a violation, litigation, proceeding, arbitration, or other dispute, whether civil, criminal, administrative or otherwise, whether pursuant to contractual obligations or otherwise.

  • Claims Bar Date means the applicable bar date by which Proofs of Claim must be Filed, as established by: (a) the Bar Date Order; (b) a Final Order of the Bankruptcy Court; or (c) the Plan.

  • Court of Appeal means the division of the Supreme Court referred to in section 7(1)(b);

  • Litigation Claims means the claims, rights of action, suits or proceedings, whether in law or in equity, whether known or unknown, that any Debtor or any Estate may hold against any Person or Entity, including, without limitation, the Causes of Action of the Debtors or their Estates, in each case solely to the extent of the Debtors’ or their Estates’ interest therein. A non-exclusive list of the Litigation Claims held by the Debtors as of the Effective Date will be Filed with the Plan Supplement, which will be deemed to include any derivative actions filed against any Debtor as of the Effective Date.

  • Claimants means any Persons who have submitted a Claim to the Receiver or to the Joint Liquidators. Where a Claim has been transferred to a third party and such transfer has been acknowledged by the Receiver or the Joint Liquidators, the transferee is a Claimant, and the transferor is not a Claimant unless the transferor has retained a Claim that has not been transferred. Where the Receiver or the Joint Liquidators have disallowed a Claim and the disallowance has become Final, then the submission of the disallowed Claim does not make the Person who submitted it a Claimant.

  • Competent Court means the Supreme Court of India or any High Court, or any tribunal or any similar judicial or quasi-judicial body that has jurisdiction in relation to issues relating to the Project.

  • Claims Objection Bar Date means the deadline for objecting to a Claim, which shall be on the date that is the later of (a) 180 days after the Effective Date and (b) such other period of limitation as may be specifically fixed by the Debtors or the Reorganized Debtors, as applicable, or by an order of the Bankruptcy Court for objecting to Claims.

  • Fraud Claim means any claim based in whole or in part upon fraud, willful misconduct or intentional misrepresentation.

  • Denied means the insurer refuses to pay a claim for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition; and

  • Adverse Benefit Determination means any of the following:

  • Third Party Claim has the meaning set forth in Section 9.5(a).

  • Urgent Care Claim means a claim for medical care or treatment where making a non-urgent care decision: (a) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, as determined by an individual acting on behalf of the plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; or (b) in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care.

  • Claims Administration means the processing and payment of claims received from Settlement Class Members by the Claims Administrator.

  • Claims Administrator means the firm proposed by Class Counsel and appointed by the Courts to administer the Settlement Amount in accordance with the provisions of this Settlement Agreement and the Distribution Protocol, and any employees of such firm.

  • First party claimant means an individual, corporation, association, partnership, or other legal entity asserting a right to payment as a covered person under an insurance policy or insurance contract arising out of the occurrence of the contingency or loss covered by such a policy or contract.

  • Denial means the process of refusing to grant a license after OCCL receives an application. This constitutes refusal of permission to operate.

  • Appeals Panel means a panel appointed by the Chief Compliance Officer pursuant to Rule 620.

  • Proof of Claim and Release means the Proof of Claim and Release form for submitting a Claim, which, subject to approval of the Court, shall be substantially in the form attached hereto as Exhibit A-2, that a Class Member must complete and submit should that Class Member seek to share in a distribution of the Net Settlement Fund.

  • Appeals Tribunal or “AT” means the Body responsible for hearing and determining appeals set out in section 9;

  • Notice and Claims Agent means Prime Clerk LLC.