Benefit Determinations. The Plan, or a person or entity working on behalf of the Plan, will administer your Benefits and determine your Benefits in accordance with the terms of this Agreement. For Claim Denials, your Explanation of Benefits is your Notice of Adverse Benefit Determination. Other Adverse Benefit Determinations are described in section 2.F.4. If you disagree with a determination made by the Plan, you may submit complaints and Appeal the decision as described in section 8.
Benefit Determinations. You will furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on your instructions and certifications with respect to Participant benefits. You are fully responsible for determining:
Benefit Determinations. The Contractholder must furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We rely solely on the Contractholder's instructions and certifications with respect to your benefits. The Contractholder is fully responsible for determining:
Benefit Determinations. For the purpose of this Addendum, BCBSKC shall have the right to determine the amount of Benefits, if any, payable for any Covered Person. Employer delegates to BCBSKC discretionary authority to construe, interpret and apply the Plan for purposes of processing claims and appeals. BCBSKC, as claims fiduciary, has the full, final, binding and exclusive discretion to construe, interpret and apply the terms of the Plan as may be necessary in order to process claims and make determinations on appeal of claims. BCBSKC shall determine the extent of the benefits (if any) to which any Participant is entitled under the Plan. Decisions by BCBSKC shall be complete, final and binding on all parties. Such determination shall be on the same basis as would be applicable under the Group Contract(s) in the absence of this Addendum. In the event of legal action against BCBSKC, by or on behalf of a Covered Person for Benefits under the Group Contract(s) with respect to a denied claim, BCBSKC, at its own expense, shall undertake the defense of such action and shall pay any judgment rendered therein. BCBSKC shall have the right to settle any such action. The Employer shall reimburse BCBSKC for the portion of any such judgment or settlement which is for a Paid Claim under the Group Contract(s), and such Paid Claim shall be administered in accordance with the terms of this Addendum, including Articles 1 and 3. Article 3
Benefit Determinations. An application for the benefits of Section 207-c of the General Municipal Law shall be processed in the following manner:
Benefit Determinations. The Participant will furnish us whatever information is necessary to establish the eligibility for and amount of annuity or other benefit due. We may rely solely on his instructions and certifications with respect to his benefits.
Benefit Determinations. A. The City shall promptly review a member’s application for GML § 207-a benefits and shall determine his eligibility within fifteen (15) business days after the City receives the application.
Benefit Determinations. NYLCare Mid-Atlantic retains authority and responsibility, after appropriate consultation with Doctors Health, to make all final benefit determinations. All communication to Enrollees regarding benefit determinations, bills, and other matters relating to NYLCare Mid-Atlantic shall be made by NYLCare Mid-Atlantic. All benefit determinations and communications with Enrollees shall be made by NYLCare Mid-Atlantic in a timely fashion.
Benefit Determinations. The HMO retains authority and responsibility, after appropriate consultation with IPA, to make all benefit determinations. All communication to Members regarding benefit determinations, bills, and other matters relating to the HMO shall be made by HMO exclusively. All benefit determinations and communications with Members shall be made by HMO in a timely fashion.
Benefit Determinations a. The City shall promptly review a firefighter's application for Section 207- a benefits and shall determine his eligibility within fifteen [15] business days after the Chief or the Chiefs designee receives the application.
