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
Standard Overdraft Practice fees apply Regardless of your Debit Card Coverage decision, if you are enrolled in Overdraft Protection and you have enough money in your linked Overdraft Protection backup account, your transaction will be approved and a transfer will be made.
Standard Overdraft Practice fees apply • You select NO, the transaction will be declined and you will NOT be charged a fee Regardless of your Business Debit Card Coverage decision, if you are enrolled in Overdraft Protection and you have enough money in your linked Overdraft Protection backup account, your transaction will be approved and a transfer will be made.
Regardless of your Debit Card Coverage decision, if you are enrolled in Overdraft Protection and you have enough money in your linked Overdraft Protection backup account, we will use the available funds from your backup account to authorize or pay transactions.
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 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 determination regarding including
Coverage decision means a final 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.
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.
Coverage decision means the approval or denial of health services by {PACE Program} 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 our contract with you. Credentialed refers to the requirement that all practitioners (physicians, psychologists, dentists and podiatrists) who serve {PACE Program} Participants must undergo a formal process that includes Department of Health Care Services (DHCS) means the single State Department responsible for administration of the federal Medicaid Program (referred to as Medi-Cal in California), California Children Services (CCS), Genetically Handicapped Persons Program (GHPP), Child Health and Disabilities Prevention (CHDP) and other health-related programs. Designated representative means a spouse, significant other, child, relative, friend or someone else you choose to involve in your care. Disputed health care service means any health care service eligible for payment under your Contract with {PACE Program} that has been denied, modified or delayed by a decision of {PACE Program} in whole or in part due to the finding that a service is not medically necessary. A decision regarding a “disputed health care service” relates to the practice of medicine and is not a coverage decision. Eligible for nursing home care means that your health status, as evaluated by the {PACE Program} Interdisciplinary Team, meets the State of California’s criteria for placement in either an Intermediate care facility (ICF), or a Skilled Nursing Facility (SNF). {PACE Program’s} goal, however, is to help you to stay in the community as long as possible, even if you are eligible for nursing home care.