Independent Health Care Appeals Program definition

Independent Health Care Appeals Program. IHCAP”)” means a program administered by the Department that provides for an external review by an Independent Utilization Review Organization of a carrier’s final coverage decision based on medical necessity or appropriateness of services.
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Independent Health Care Appeals Program means the external appeals process for a Covered Person or provider on behalf of the Covered Person with the Covered Person's consent, to appeal a decision of a carrier to deny, reduce or terminate services or payment of benefits resulting from a decision by a carrier with respect to the Covered Person which services are otherwise covered under the health benefits plan. Independent Utilization Review Organization (IURO): means an independent organization with which the Department contracts to provide independent reviews through the Independent Health Care Appeals Program of carrier determinations regarding Medical Necessity or appropriateness of services which are contested by the Covered Person or a provider on behalf of the Covered Person..
Sample 1Sample 2Sample 3
Independent Health Care Appeals Program means a program administered by the Department which provides for a review by an Independent Utilization Review Organization.
Sample 1Sample 2Sample 3

Examples of Independent Health Care Appeals Program in a sentence

  • No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of arbitration pursuant to this subsection.

Related to Independent Health Care Appeals Program

  • Health care plan means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

  • Non-Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has not been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Participating Hospice Care Program Provider means a Hospice Care Program Provider that either: (i) has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield to provide services to participants in this benefits program, or; (ii) a Hospice Care Program Provider which has been designated by a Blue Cross and/or Blue Shield Plan as a Participating Provider Option program.

  • Health care decision means any decision regarding the health care of the prospective donor.

  • Licensed health care provider means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board.

  • Managed care plan means a health benefit plan that either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by the health carrier.

  • Independent educational evaluation means an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.

  • Licensed health care professional means a person who possesses a professional medical license that is valid in Oregon. Examples include, but are not limited to, a registered nurse (RN), nurse practitioner (NP), licensed practical nurse (LPN), medical doctor (MD), osteopathic physician (DO), respiratory therapist (RT), physical therapist (PT), physician assistant (PA), or occupational therapist (OT).

  • Dependent care assistance program means a benefit plan

  • Emergency medical care provider means an individual who has been trained to provide emergency and nonemergency medical care at the first responder, EMT-basic, EMT-intermediate, EMT-paramedic, paramedic specialist or other certification levels recognized by the department before 1984 and who has been issued a certificate by the department.

  • Child Care Program means a person or business that offers child care.

  • Qualified mental health professional means a licensed medical practitioner or any other person meeting the qualifications specified in OAR 309-019-0125.

  • Non-Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Managed health care system means: (a) Any health care

  • Non-Administrator Coordinated Home Care Program means a Coordinated Home Care Program which does not have an agreement with the Claim Administrator or a Blue Cross Plan but has been certified as a home health agency in accordance with the guidelines established by Medicare.

  • Qualified medical provider means the same as that term is defined in Section 26-61a-102.

  • Health care provider or "provider" means:

  • Participating Retail Health Clinic means a Retail Health Clinic which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Participating Home Infusion Therapy Provider means a Home Infusion Therapy Provider who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Federal Health Care Program has the meaning set forth in 42 U.S.C. 1320a-7b(f).

  • Non-Participating Clinical Professional Counselor means a Clinical Professional Counselor who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Health Care Operations shall have the meaning given to such term under the HIPAA 2 Privacy Rule in 45 CFR § 164.501.

  • Managed Care Program means the process that determines Medical Necessity and directs care to the most appropriate setting to provide quality care in a cost-effective manner, including Prior Authorization of certain services.

  • Care Plan means a licensee's written description of a resident's needs, preferences, and capabilities, including by whom, when, and how often care and services are to be provided.