Coverage decision definition

Coverage decision means the approval or denial of benefits for health care services substantially based on a finding that the provision of a particular service is included or excluded as a covered benefit under the terms and conditions of the health care service plan contract. A “coverage decision” does not encompass a plan or contracting provider decision regarding a Disputed Health Care Service.

Coverage decision means: ▪ An initial determination by us or our representative that results in non-coverage of a health care service; ▪ A determination by us that an individual is not eligible for coverage under the Policy; ▪ Any determination by us that results in the rescission of an individual’s coverage under the Policy. ▪ A coverage decision includes a nonpayment of all or any part of a claim. ▪ A coverage decision does not include: ♦ An adverse decision as described above; or ♦ A pharmacy inquiry.

Coverage decision means the approval or denial of health

Examples of Coverage decision in a sentence

• If Your Network Provider does not dispute a Coverage decision, You may request reconsideration of that decision as explained in the Grievance Procedure section of this EOC.

• If Your Provider does not dispute a Coverage decision, You may request reconsideration of that decision as explained in the Grievance Procedure section of this Contract.Termination of Providers’ ParticipationKFBHP (or its affiliate or third party vendor on behalf of KFBHP) or any Network Provider may end their relationship with each other at any time.

• If Your Network Provider does not dispute a Coverage decision, You may request reconsideration of that decision as explained in the grievance procedure section of this Member Handbook.

• If this occurs: • You may submit a claim to BCBST to obtain a Coverage decision concerning whether the Plan will Cover that service.

• The participation agreement requires Network Providers to fully and fairly explain the administrator’s Coverage decisions to You, upon request, if You decide to request that the administrator reconsider a Coverage decision.

More Definitions of Coverage decision

Coverage decision means the approval or denial of health care items or services by a participating provider or a health care professional who is employed by or otherwise receives compensation or payment for items and services furnished under CalCare from a participating provider, substantially based on a finding that the provision of a particular service is included or excluded as a covered item or service under CalCare. A “coverage decision” does not encompass a decision regarding a disputed health care item or service;

Coverage decision means a final adverse decision

Coverage decision means a determination regarding including

Coverage decision means a final adverse decision based on medical necessity. This definition does not include a denial of coverage for a service or treatment specifically listed in plan or evidence of coverage documents as excluded from coverage.

Coverage decision means an initial determination by Delta Dental that results in noncoverage of a Health Care Service; a determination by Delta Dental that an Enrollee is not eligible for coverage under our health benefit plan; or any determination by Delta Dental that results in the rescission of an Enrollee’s coverage under a health benefit plan. Coverage Decision includes nonpayment of all or any part of a claim.

Coverage decision means our initial determination that results in non-coverage of a health care service. This includes our determination that you are not eligible for coverage under our plan or that your coverage has ended. Coverage decision includes non-payment of all or any part of a claim but does not include an adverse decision.

Coverage decision means a final adverse decision based on medical necessity. This definition does not include a denial of coverage for a service or treatment specifically listed in plan or evidence of coverage documents as excluded from coverage, or a denial of coverage for a service or treatment that has already been received and for which the enrollee has no financial liability.