Claims Adjudication definition

Claims Adjudication means Contractor’s final decision to pay claims submitted or deny them after comparing claims to the benefit or coverage requirements.
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Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant to the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or Member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any Copayment/Deductible or Coinsurance payable by a Member, as well as drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof.
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Claims Adjudication means processing of electronic claims for prescriptions which includes full compliance with 340B Patient eligibility requirements, which include but are not limited to: verifying Patient and provider eligibility and formulary status of prescribed medication. The electronic claims adjudication process shall include a real time Lower of Pricing analysis to verify the lowest cost alternative for the specific claim, communicated back to the CPN at the time of claims adjudication.
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Examples of Claims Adjudication in a sentence

  • If the employee disputes the decision, the employee may request to have the claim reviewed by a claims review committee comprised of three independent and qualified medical doctors agreed to by the Claims Adjudication Committee.


More Definitions of Claims Adjudication

Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a member, as well as concurrent (on-line at point of service) drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof.
Sample 1Sample 2Sample 3
Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a
Sample 1
Claims Adjudication means the determination of whether a given Claim is entitled to reimbursement pursuant the terms and conditions of a Benefit Plan and the amount payable to or by a Network Participant or member pursuant to such Benefit Plan, the applicable Network Contract and any other applicable factors, including any copayment/deductible or coinsurance payable by a member, as well as concurrent (on- line at point of service) drug utilization review. Claims Adjudication shall accommodate any e-prescribing procedures that may be adopted after the date hereof. The cost to the Employer and the Member will be the lesser of the MAC price, the Ingredient Cost, the Usual and Customary price, or the cash price.
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Related to Claims Adjudication

  • Appeal means a request for a review of the Floodplain Administrator's interpretation of any provision of this ordinance.

  • Claimant means a person who believes that he or she is being denied a benefit to which he or she is entitled hereunder.

  • Claim means any action, claim, obligation, liability, expense, lawsuit, demand, suit, inquiry, hearing, investigation, notice of a violation, litigation, proceeding, arbitration, or other dispute, whether civil, criminal, administrative or otherwise, whether pursuant to contractual obligations or otherwise.

  • Denied means the insurer refuses to pay a claim for any reason other than for claims not paid for failure to meet the waiting period or because of an applicable preexisting condition; and

  • Adverse Benefit Determination means any of the following:

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

  • Claims Administrator means the firm proposed by Class Counsel and appointed by the Courts to administer the Settlement Amount in accordance with the provisions of this Settlement Agreement and the Distribution Protocol, and any employees of such firm.