Common use of Verify Member Eligibility Clause in Contracts

Verify Member Eligibility. Determine the Medical Necessity of medical transportation services in accordance with the Medical Necessity standards set forth in the applicable Administrative Manual. Any claim that would be denied on the basis of Medical Necessity shall be referred to the Contracted Health Plan prior to denial. Except as otherwise provided in the applicable Administrative Manual, (a) the Contracted Health Plan, or its designee, shall be sorely responsible for notifying the Member of the denial of any claim; and (b) CONTRACTOR shall not contact the Member with respect to any denial of claims. If the Contracted Health Plan approves the claim, it shall notify CONTRACTOR of the approval, and CONTRACTOR shall promptly pay the claim. Notwithstanding the foregoing, if Customer's referral authorization is included in the claims submission, then the Medical Necessity of the claims will be deemed to be determined, and further review will not be required.

Verify Member Eligibility. Determine the Medical Necessity of medical transportation services in accordance with the Medical Necessity standards set forth in the applicable Administrative Manual. Any claim that would be denied on the basis of Medical Necessity shall be referred to the Contracted Health Plan prior to denial. Except as otherwise provided in the applicable Administrative Manual, (a) the Contracted Health Plan, or its designee, shall be sorely solely responsible for notifying the Member of the denial of any claim; and (b) CONTRACTOR shall not contact the Member with respect to any denial of claims. If the Contracted Health Plan approves the claim, it shall notify CONTRACTOR of the approval, and CONTRACTOR shall promptly pay the claim. Notwithstanding the foregoing, if Customer's referral authorization is included in the claims submission, then the Medical Necessity of the claims will be deemed to be determined, and further review will not be required.