Claim Adjudication definition

Claim Adjudication means the process whereby NHC adjudicates a claim of a Qualified Person to determine, among other things, whether such claim is a type which is covered by the PHSP and whether such claim has been paid by the Qualified Person;
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Claim Adjudication or "Adjudication" means the process which BCBSNC uses to apply the criteria and parameters of the Group Health Plan to determine eligibility for coverage of pharmacy benefit management services, perform concurrent (on-line at point of service) Drug Utilization Reviews and determine drug pricing reimbursement amounts.
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Examples of Claim Adjudication in a sentence

  • The point in time following the Claim Adjudication Date when reimbursement is generated for services, either initiated by date of Electronic Funds Transfer (EFT) or processes to generate a paper check.

  • Oral surgery services that are reported with CPT medical procedure codes must be submitted as a Health Care Claim: Professional (837P) transaction to either Highmark or UCCI according to which payer is responsible for the patient’s oral surgery coverage.Real-Time Claim Adjudication and Estimation Highmark real-time claim adjudication and claim estimation processes leverage the Electronic Claim1 transaction.

  • Any payment to the provider will be made by Highmark West Virginia.Transaction LimitationsReal-time Health Care Claim: Institutional (837I) submissions are limited to 50 lines per claim.Real-Time Claim Adjudication and Estimation Highmark West Virginia real-time claim adjudication and claim estimation processes leverage the electronic claim1 transaction.

  • Under the terms of the Prior Service Claim Adjudication Service Agreement between the Prior Service Trust Fund Administration and the Social Security Administration of the Federated States of Micronesia, the FSM Social Security Administration is to provide for the processing of benefit claims and to assist in the monitoring of continuing eligibility under the Prior Service Program.

  • Currently, the state Bureau of Field Enforcement can issue citations but only for payment up to the state minimum wage; the Department of Labor Standards Enforcement Wage Claim Adjudication unit can adjudicate higher minimum wages, but it is up to the worker to collect on the judgment (Koonse 2015).

  • For more information on HTTPS connectivity specifications for demonstration of 837 Estimation submissions, refer to the Real-Time Claim Adjudication and Estimation Connectivity Specifications.

  • Oral surgery services that are reported with CPT medical procedure codes must be submitted as a Health Care Claim: Professional (837P) transaction to either Highmark West Virginia or UCCI according to which payer is responsible for the patient’s oral surgery coverage.Real-Time Claim Adjudication and Estimation Highmark West Virginia real-time claim adjudication and claim estimation processes leverage the Electronic Claim1 transaction.

  • DLSE consists of five major units: • Wage Claim Adjudication: DLSE is responsible for adjudicating wage claims on the behalf of workers who file claims for nonpayment of wages, overtime, or vacation pay.

  • The DLSE fulfills these mandates through its major programs: the Wage Claim Adjudication (WCA), the Bureau of Field Enforcement (BOFE), the Public Works program (PW), and the Discrimination Complaint Investigation Unit (DCI).

  • Figure 4.3: Wage Claim Adjudication and BOFE ProceduresSource: Bar-Cohen & Carrillo, 2002 Wage Claim AdjudicationEmployees who believe they have not been paid the wages due them under the law can file a complaint with DLSE.

Related to Claim Adjudication

  • Final Adjudication has the meaning set forth in Section 5.5.

  • Claim Form or “Proof of Claim Form” means the form, substantially in the form attached hereto as Exhibit 2 to Exhibit A, that a Claimant must complete and submit should that Claimant seek to share in a distribution of the Net Settlement Fund.

  • Third party claimant means any individual, corporation, association, partnership, or other legal entity asserting a claim against any individual, corporation, association, partnership, or other legal entity insured under an insurance policy or insurance contract.

  • Adverse Benefit Determination means any of the following:

  • Indemnified Claim has the meaning set forth in Section 8.2.

  • Claim means any claim, action, cause of action, demand, lawsuit, arbitration, inquiry, audit, notice of violation, proceeding, litigation, citation, summons, subpoena, or investigation of any nature, whether civil, criminal, administrative, regulatory or other, and whether at law, in equity or otherwise brought against an Indemnified Person.

  • Indemnification Claim has the meaning set forth in Section 12.3.

  • Indemnified Matter has the meaning specified in Section 11.4 (Indemnities).

  • Third Party Claim has the meaning set forth in Section 8.3.

  • Competent Court means the Supreme Court of India or any High Court, or any tribunal or any similar judicial or quasi-judicial body that has jurisdiction in relation to issues relating to the Project.

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

  • Adjudication means agency process for the formulation of an order;

  • Final Determination means the final resolution of liability for any Tax for any taxable period, by or as a result of (i) a final and unappealable decision, judgment, decree or other order by any court of competent jurisdiction; (ii) a final settlement with the IRS, a closing agreement or accepted offer in compromise under section 7121 or section 7122 of the Code, or a comparable agreement under the laws of other jurisdictions, which resolves the entire Tax liability for any taxable period; (iii) any allowance of a refund or credit in respect of an overpayment of Tax, but only after the expiration of all periods during which such refund may be recovered by the jurisdiction imposing the Tax; or (iv) any other final disposition, including by reason of the expiration of the applicable statute of limitations.

  • Fraud Claim means any claim based in whole or in part upon fraud, willful misconduct or intentional misrepresentation.

  • Adjudicatory hearing means a hearing to determine:

  • Indemnification Claim Notice has the meaning set forth in Section 11.3.

  • Indemnified Claims shall include any and all claims, demands, suits, causes of action, judgments and liability of every character, type or description, including all reasonable costs and expenses of litigation, mediation or other alternate dispute resolution mechanism, including attorney and other professional fees for: (1) damage to or loss of the property of any person (including, but not limited to the City, the Contractor, their respective agents, officers, employees and subcontractors; the officers, agents, and employees of such subcontractors; and third parties); and/or (2) death, bodily injury, illness, disease, worker's compensation, loss of services, or loss of income or wages to any person (including but not limited to the agents, officers and employees of the City, the Contractor, the Contractor’s subcontractors, and third parties), ii. "Fault" shall include the sale of defective or non- conforming deliverables, negligence, willful misconduct or a breach of any legally imposed strict liability standard.

  • Indemnity Claim has the meaning set forth in Section 8.3.

  • Court of Appeal means the division of the Supreme Court referred to in section 7(1)(b);

  • Direct Claim has the meaning set forth in Section 8.05(c).

  • Third Party Claim Notice shall have the meaning set forth in Section 6.5(a).

  • Adverse determination shall have the meaning set forth in Section 19.7.

  • Indemnitee has the meaning assigned to such term in Section 9.03(b).

  • Claim for Benefits means a request for a Plan benefit or benefits made by a Member in accordance with the Plan’s Appeals Procedures, including any Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests for benefit payment).

  • Liability Claim has the meaning set forth in Section 7.2(a).

  • Indemnifiable Claim means any Claim based upon, arising out of or resulting from (i) any actual, alleged or suspected act or failure to act by Indemnitee in his or her capacity as a director, officer, employee or agent of the Company or as a director, officer, employee, member, manager, trustee or agent of any other corporation, limited liability company, partnership, joint venture, trust or other entity or enterprise, whether or not for profit, as to which Indemnitee is or was serving at the request of the Company as a director, officer, employee, member, manager, trustee or agent, (ii) any actual, alleged or suspected act or failure to act by Indemnitee in respect of any business, transaction, communication, filing, disclosure or other activity of the Company or any other entity or enterprise referred to in clause (i) of this sentence, or (iii) Indemnitee’s status as a current or former director, officer, employee or agent of the Company or as a current or former director, officer, employee, member, manager, trustee or agent of the Company or any other entity or enterprise referred to in clause (i) of this sentence or any actual, alleged or suspected act or failure to act by Indemnitee in connection with any obligation or restriction imposed upon Indemnitee by reason of such status. In addition to any service at the actual request of the Company, for purposes of this Agreement, Indemnitee shall be deemed to be serving or to have served at the request of the Company as a director, officer, employee, member, manager, trustee or agent of another entity or enterprise if Indemnitee is or was serving as a director, officer, employee, member, manager, trustee or agent of such entity or enterprise and (i) such entity or enterprise is or at the time of such service was a Controlled Affiliate, (ii) such entity or enterprise is or at the time of such service was an employee benefit plan (or related trust) sponsored or maintained by the Company or a Controlled Affiliate, or (iii) the Company or a Controlled Affiliate directly or indirectly caused or authorized Indemnitee to be nominated, elected, appointed, designated, employed, engaged or selected to serve in such capacity.