Benefits Determination definition

Benefits Determination as those terms are defined in the most recent version of the Trusted Exchange Framework and Common Agreement as published in the Federal Register. Prior to publication of the Trusted Exchange Framework and Common Agreement in the Federal Register, those terms shall have the meaning set forth in the Draft Trusted Exchange Framework published by the Office of the National Coordinator for Health Information Technology on January 5, 2018.
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Benefits Determination means a determination made by any federal or state agency as to whether an individual qualifies for federal or state benefits for any purpose other than health care (for example, Social Security disability benefits) to the extent permitted or required by Applicable Law. Disclosure of PHI for this purpose may require an Authorization if the conditions of 45 C.F.R. part 154.512(k)(6) are not met.
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Examples of Benefits Determination in a sentence

  • This section applies when This Plan is the Secondary Plan in accordance with the Order of Benefits Determination Rules outlined above.

  • Order of Benefits Determination RulesWhen a person is covered by two or more plans, the rules for determining the order of benefit payments are as follows:(a) The primary plan pays or provides its benefits according to its terms of coverage and without regard to the benefits under any other plan.

  • Piedmont will make a preliminary determination as to whether the Adverse Benefits Determination is eligible for an external appeal.

  • Effect on Benefits When a Member is covered under this Plan and another plan that together would pay more than the Allowable Expense with respect to a Covered Service, this Plan will pay benefits according to the Order of Benefits Determination rules and this paragraph.

  • If You are known to have group coverage through any other health plan or insurer, responsibility for payment of benefits is determined by following the Rules Establishing the Order of Benefits Determination, formulated by the Insurance Commissioner of the State of California and incorporated in this Certificate.

  • The Notice of Adverse Benefits Determination, issued pursuant to Section 1850.210(a)-(e) shall 358 contain the following information: 359 360 1.

  • If this Plan is Secondary Plan under the Order of Benefits Determination rules, however, this Plan will deduct the Primary Plan’s payment from this Plan’s Maximum Allowable Amount for the Covered Service and then apply the applicable deductibles, co-insurance and co-pay provisions under this Plan.

  • A Notice of Adverse Benefits Determination, issued pursuant to Section 1850.210(g), shall 375 specify the following: 376 (1) The reason that the medical necessity criteria were not met, including a citation of the 377 applicable regulation.

  • The requirements to exchange for purposes of Treatment, Public Health, and Benefits Determination will remain the same as proposed in TEF Draft 1.

  • This Subsection 4 applies when, in accordance with Subsection 3 “Order of Benefits Determination Rules,” This Plan is a Secondary Plan as to one or more other plans.

Related to Benefits Determination

  • Administrative merits determination means certain notices or findings of labor law violations issued by an enforcement agency following an investigation. An administrative merits determination may be final or be subject to appeal or further review. To determine whether a particular notice or finding is covered by this definition, it is necessary to consult section II.B. in the DOL Guidance.

  • Expert Determination has the meaning given to it in Clause 18.3(a) (Expert Determination).

  • Adverse Benefit Determination means any of the following:

  • Eligibility Determination means an approval or denial of eligibility and a renewal or termination of eligibility as set forth in OAR 410-200-0015;¶

  • Claim Determination Period means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

  • Self-Determination means a philosophy and process by which individuals with developmental disabilities are empowered to gain control over the selection of support services that meet their needs. The basic principles of self-determination are:

  • Event Determination Date means either:

  • Benchmark Determination Date means (a) if the Benchmark is LIBOR, the LIBOR Determination Date, (b) if the Benchmark is Term SOFR, the date that is two Business Days before the first day of the applicable Accrual Period, (c) if the Benchmark is Compounded SOFR, the date that is five Business Days before the last day of the applicable Accrual Period and (d) if the Benchmark is any other rate, the date determined by the Trust according to Section 2.16 of the Indenture.

  • SOFR Determination Date has the meaning specified in the definition of “Daily Simple SOFR”.

  • Payment Determination Date means, with respect to any Payment Date, one (1) Business Day immediately preceding such Payment Date.

  • Accounting Restatement Determination Date means the earliest to occur of: (a) the date the Board, a committee of the Board, or one or more of the officers of the Company authorized to take such action if Board action is not required, concludes, or reasonably should have concluded, that the Company is required to prepare an Accounting Restatement; and (b) the date a court, regulator, or other legally authorized body directs the Company to prepare an Accounting Restatement.

  • Standard of Conduct Determination shall have the meaning ascribed to it in Section 9(b) below.

  • Final Determination Date means the following:

  • TIA Applicability Determination As defined in Section 12.12.

  • Disability benefits means any cash payments which are payable to a covered individual for all or part of a period of disability pursuant to P.L.1948, c.110 (C.43:21-25 et al.).

  • Interest Determination Date means, with respect to a Rate of Interest and Interest Accrual Period, the date specified as such hereon or, if none is so specified, (i) the first day of such Interest Accrual Period if the Specified Currency is Sterling or (ii) the day falling two Business Days in London for the Specified Currency prior to the first day of such Interest Accrual Period if the Specified Currency is neither Sterling nor euro or (iii) the day falling two TARGET Business Days prior to the first day of such Interest Accrual Period if the Specified Currency is euro.

  • SOFR Determination Time means 3:00 p.m. (New York time) on the U.S. Government Securities Business Day, at which time Compounded SOFR is published on the FRBNY’s Website.

  • Monthly Report Determination Date The meaning specified in Section 10.7(a).

  • Final Determination means a determination within the meaning of Section 1313 of the Code or any similar provision of state or local Tax Law.

  • Initial determination means the first child custody determination concerning a particular child.

  • Final Adverse Benefit Determination means an adverse benefit determination that is upheld at the completion of a health plan issuer’s internal appeals process.

  • Index Determination Date means, in relation to any Index, a date on which such Indexfalls to be determined in accordance with the Conditions;

  • Reset Determination Date means, in respect of the First Reset Period, the second Business Day prior to the First Reset Date and, in respect of each Subsequent Reset Period thereafter, the second Business Day prior to the first day of each such Subsequent Reset Period;

  • Distribution Determination Date means, in respect of any Distribution Period, that number of business days prior thereto as is set out in the applicable Pricing Supplement or on the face of the relevant Perpetual Security;

  • LIBOR Determination Date With respect to any Interest Accrual Period for the LIBOR Certificates, the second London Business Day preceding the commencement of such Interest Accrual Period.

  • Retirement Benefits means benefits paid by reference to reaching, or the expectation of reaching, retirement or, where they are supplementary to those benefits and provided on an ancillary basis, in the form of payments on death, disability, or cessation of employment or in the form of support payments or services in case of sickness, indigence or death. In order to facilitate financial security in retirement, these benefits may take the form of payments for life, payments made for a temporary period, a lump sum, or any combination thereof;