Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denials. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this Contract.
Appears in 41 contracts
Samples: Preferred Provider Organization Insurance Contract, Preferred Provider Organization Insurance Contract, Preferred Provider Organization Insurance Contract
Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denials. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this ContractPolicy.
Appears in 9 contracts
Samples: Participating Provider Organization Insurance Policy, Insurance Policy, Participating Provider Organization Insurance Policy
Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denialsdenials and Referrals. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this Contract.
Appears in 5 contracts
Samples: Preferred Provider Organization Contract, Preferred Provider Organization Contract, Preferred Provider Organization Contract
Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denialsdenials and Referrals. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this ContractPolicy. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this ContractPolicy.
Appears in 2 contracts
Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity Medical Necessity or experimental or investigational determination. For example, Our Claim claim determination procedure applies to contractual benefit denials. If You disagree with Our claim determination, You you may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity Medical Necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this Contract.
Appears in 1 contract
Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denialsdenials and Referrals. If You disagree with Our claim determination, You you may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this Contract.
Appears in 1 contract
Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denials. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this ContractCertificate. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this ContractCertificate.
Appears in 1 contract
Samples: Student Vision Insurance Policy
