Examples of Disputed Health Care Service in a sentence
A written reconsideration decision will be provided; and• If you still remain dissatisfied with the reconsideration decision following review by Health Net, you may request an independent review or go through the binding arbitration remedy set forth in the "Independent Medical Review of Grievances Involving a Disputed Health Care Service" and "Binding Arbitration" provisions of the "General Provisions" section of this EOC.
If the IMR determines the service is Medically Necessary, Health Net will provide the Disputed Health Care Service.
It does not include a plan or contracting provider decision regarding a Disputed Health Care Service.
If the Member receives a decision by the Director of the Department that a Disputed Health Care Service is Medically Necessary, Health Plan will promptly implement the decision.In the case of reimbursement for services already provided, Health Plan will reimburse the provider or Member within five (5) working days.
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The request for an Administrative Review must be submitted in writing to CalPERS within thirty(30) days from the date of the DMHC FABD or, the IMR determination letter, in cases involving a Disputed Health Care Service, or Experimental or Investigational determination.
Disputed Health Care Service - any Health Care Service eligible for coverage and payment under your Blue Shield Plan that has been denied, modified or delayed by Blue Shield or one of its contracting providers, in whole or in part because the service is deemed not Medically Necessary.
The Member will receive written notice of an adverse benefit determination (including Coverage Decisions and Disputed Health Care Service decisions) from the HMO.
Disputed Health Care Service grievances: A disputed health care service grievance concerns any heath care service eligible for coverage and payment under this Evidence of Coverage booklet that has been denied, modified, or delayed in whole or in part due to a finding that the service is not medically necessary.
The complaint and appeals process, including independent medical review from the California Department of Insurance, is described in the "Grievance and Appeals Process" and "Independent Medical Review of Grievances Involving a Disputed Health Care Service " sections of this Policy.