Benefit determination means a decision of the enrollee's entitlement to payment for

Benefit determination means a decision to approve or deny a request to provide or make payment for a health care service or treatment.

Benefit determination means a determination by the Plan Administrator on a claim for benefits under the Plan, whether or not an Adverse Benefit Determination.

Examples of Benefit determination in a sentence

An Expedited Appeal process is available for review of the Adverse Benefit Determination involving a situation where the time frame of the standard Dental Necessity Appeal would seriously jeopardize Your life, health or ability to regain maximum function.
The processes the Contractor implements to handle Appeals of an Adverse Benefit Determination and Grievances, as well as the processes to collect and track information about them.
In the case of a Provider, the Adverse Benefit Determination may include, but is not limited to, delay or non-payment for covered services.
In the case of a Member, the Adverse Benefit Determination may include determinations on the health care services a Member believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the Member).
An expression of dissatisfaction, regardless of whether identified as a “Grievance,” received by any employee of the Contractor orally or in writing about any matter or aspect of the Contractor or its operation, other than a Contractor Adverse Benefit Determination as defined in this Contract.

More Definitions of Benefit determination

Benefit determination means a decision to approve or deny a request to provide or

Benefit determination means a decision by an MCO about a request for services (also referred to as “prior authorizations” or “medical necessity reviews”).

Benefit determination means a decision of the enrollee's entitlement to payment for covered health care services as defined in an agreement with the payor or its delegate.

Benefit determination means a notification, in writing, approved by the Tribal Health Services Professionals, issued by the Program Administrator to the applicant (or his or her Financial Conservator or Power of Attorney), that indicates a finding of approval or denial of his or her application for Disability Benefits and/or addresses a Participant’s Continued Qualification for the Program, wherein Disability Benefit may be continued, suspended or terminated.

Benefit determination has the meaning ascribed in Subsection 1.1(a);

Benefit determination means a decision involving any issue related to a claimant's qualification or eligibility for benefits, including monetary, nonmonetary, and separation issues. The term also includes a claimant's overpayment amount and determinations regarding waiver of overpayment recovery.

Benefit determination means a decision made by the payor or its delegate to the