Common use of Coverage Determinations Clause in Contracts

Coverage Determinations. PLAN or its designated representative shall have sole authority to determine: (a) what is a Covered Service; (b) who is a Subscriber; and (c) the amount and application of Cost Sharing Provisions. DENTIST further acknowledges that such determinations of Covered Services, Non-Covered Services, Subscribers and Cost Sharing Provisions may vary among Group Contracts. Except as otherwise provided in this Agreement, the obligation of PLAN to pay DENTIST pursuant to this Agreement is conditioned upon the determination that the person receiving services, supplies, products, or accommodations from DENTIST is a Subscriber and that such services, supplies, products, or accommodations are Covered Services. DENTIST agrees to accept such determination of the foregoing, which shall be made in accordance with the PLAN’s policies and procedures.