For these purposes, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is contractually required to comply with Aetna's utilization ma...
The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of ...
Preauthorization or precertification* This is an important process. It is approval a person gets for care before receiving the care. This helps people know if the care is covered by a health plan. People should check with their plan to see what kind of service needs this approval. This can...
agreement with Pray and that the appraisal was deficient, a redetermination of the loss would have been necessary. Dr. Mitchell could not have anticipated that the jury would fix the amount of loss, for he failed to introduce the evidence necessary to give them a basis for that determination...
no further clinical review will berequired. Once we receive the pre-treatmentestimate, we will let you know whether ornot your specific plan covers the servicesinvolved and an estimate of your benefits will be sent to you. Our determination may depend, in part, on whether the dentist providing...
thereby provide himself with the opportunity for cross-examination of the physician." Id. Such hearsay evidence alone may therefore support an agency determination. Johnson v. United States, 628 F.2d 187, 190-91 (D.C. Cir. 1980). A residuum of corroborating evidence of the type admissible ...
is required of all Aetna participating providers and members in applicable plan designs. For precertification of Avsola, Inflectra, Remicade, or Renflexis,call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, seeSpecialty Pharmacy Precertificat...
disease, illness or injury and the diagnosis is idiopathic short stature, GH is not a covered plan benefit. When GH is not a covered plan benefit, medical necessity language should not be included within the review determination rationale. This a contractual denial and not based upon medical ...
Studies were analyzed by FDA-cleared software service that carries out AI-driven coronary artery segmentation and labeling, lumen and vessel wall determination, plaque quantification and characterization with comparison to ground truth of consensus by 3 Level 3 (L3) expert readers. CCTAs were analyzed...
of a message packet. The determination of which node will transmit for each time frame 152 is determined by transmissions over a control link as illustrated by the primed numbers in FIG. 3. The time frame 152 on the control link is divided into a set of time slots (or bit groups) 154...