Coverage Determination Clause Samples
The Coverage Determination clause defines the process by which an insurance provider decides whether a particular claim or service is covered under the terms of a policy. Typically, this involves evaluating the specifics of a claim against the policy's coverage limits, exclusions, and conditions, and may require the submission of supporting documentation by the insured. By establishing clear procedures and criteria for making coverage decisions, this clause ensures transparency and helps prevent disputes over what is or is not covered.
Coverage Determination. An ICDS Plan decision to approve or deny a request for a covered service, also referred to as Prior Authorization decision.
Coverage Determination. Coverage shall be placed on the basis of proven certification and experience on January 1 st each year, or where the employee is not on staff at January 1st, on the date that the employee commences employment.
Coverage Determination. Coverage shall be placed on the basis of proven certification and experience on January 1st each year, or where the employee is not on staff at January on the date the employee commences employment. The maximum amount of insurance on an employee shall be six hundred percent (600%) of the Category minimum of the teachers' salary scale.
Coverage Determination. If we provide you with prior written notice that a service is a Covered Health Care Service, we will not later retract such determination after the services are furnished unless the determination was based upon material misrepresentation by you or your Physician.