Examples of Allowable Claim in a sentence
The Allowable Claim Limit for charges for medical and surgical supplies made by a provider may be based upon the invoice price (cost) to the provider, plus an additional 12%.
The Allowable Claim Limit for any covered services may be calculated based upon industry-standard resources including, but not limited to, published and publicly available fee and cost lists and comparisons, or any combination of such resources that in the opinion of the Plan Administrator results in the determination of a reasonable expense under the Plan.
In the event that insufficient information is available to determine Allowable Claim Limits for specific services or supplies using the guidelines listed in Section 2 above, Allowable Claim Limits will be determined considering the most comparable services or supplies based upon comparative severity and/or geographic area to determine the Allowable Claim Limit.
In the event that insufficient information is available to identify the Medicare allowed amount, the Allowable Claim Limit for such services shall be to the extent available either the outpatient or inpatient Medicare allowed amount for the service, plus an additional 20%.
The Allowable Claim Limit for these services will be calculated using one or more of the industry-standard resources, plus an additional 12%.
The Allowable Claim Limit for these services may be determined based upon the 60th percentile of Fair Health (FH®) Allowed Benchmarks.Comparable Services or Supplies.
The Allowable Claim Limits will not include any charges for which the Plan Administrator cannot identify or understand the item(s) being billed.
The Allowable Claim Limits will not include any identifiable billing mistakes including, but not limited to, upcoding, duplicate charges, and charges for services not performed.
The Allowable Claim Limits for providers of service who are directly contracted with the DDM will be the negotiated rate as agreed under the contract.
Determination of calculated Loss• Add the following values, as applicable for a given Claim, to determine the calculated Loss:o Unpaid principal;o Unpaid interest; ando Acceptable advances/expenses as Allowable Claim expenses tables below.Step 2.