Claim Adjudication. The MCOP shall have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures shall be provided to noncontracting providers within 30 calendar days of a request. The MCOP shall inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information shall be initiated by the MCOP and not only in response to provider requests. The MCOP shall have a sufficient number of provider service representatives who are knowledgeable of the MCOP's claims system.
Claim Adjudication. The Insurance Company adjudicates claims in accordance with its internal administrative guidelines. Any rebates or refunds on Member’s Covered Services are credited against the Group’s experience for rating purposes.
Claim Adjudication. The MCOP shall have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures shall be provided to noncontracting providers within 30 calendar days of a request. The MCOP shall inform providers of its ability to electronically process and adjudicate claims and the process for submission. Such information shall be initiated by the MCOP and not only in response to provider requests. The MCOP shall have a sufficient number of provider service representatives who are knowledgeable of the MCOP's claims system. If there is information on the provider network management (PNM) system generated provider master file (PMF) or any other supplemental file generated by an ODM system to support claims payment, the MCOP must use the PMF or other ODM system generated supplemental file information to adjudicate the claim(s).
Claim Adjudication. Administrator shall adjust, process, and approve claims associated with validly issued Protection Plans in accordance with the respective Terms and Conditions.
Claim Adjudication. The Insurance Company adjudicates claims in accordance with its internal DGPLQLVWUDWLYH JXLGHOLQHV $Q\ UHEDWHV RU UH are credited against thH *URXS¶V H[SHUpuLrpHosQesF. H IRU UDWLQJ
Claim Adjudication. The Plan adjudicates claims in accordance with its internal administrative guidelines. Any rebates or refunds on Member’s Covered Services are credited against the Group’s experience for rating purposes.
Claim Adjudication. Medco will adjudicate claims for prescription drug benefits in accordance with Medco’s TelePAID System and the applicable Plan Design. Disapproved claims will be transmitted via TelePAID to the submitting pharmacy with a brief explanation of the cause or causes for disapproval. Should SPONSOR determine that a previously disapproved claim should be approved, and so direct Medco, adjudication of the claim will be accomplished promptly by Medco. Medco is obligated to pay Participating Pharmacies for all claims adjudicated through the TelePAID System. SPONSOR will pay Medco for these claims pursuant to Schedule A, Section
Claim Adjudication. Medco will adjudicate and pay approved claims for prescription drug benefits in accordance with Medco’s TelePAID System and the applicable Plan Design. Should SPONSOR determine that a previously disapproved claim should be approved, and so direct Medco, adjudication of the claim will be accomplished promptly by Medco. SPONSOR will pay Medco for claims adjudicated through the TelePAID System, pursuant to Schedule A, Section 2. Medco will promptly refer to SPONSOR all non-routine inquiries by insurance departments, attorneys, claimants, or other persons following the denial of any claims.
Claim Adjudication. The process of paying claims submitted or denying them after comparing the claim data elements to the benefit or coverage requirements.
