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Benefit determination

Updated on April 26, 2021


During the claims adjudication process, claims are evaluated to determine whether the services provided to the member have been delivered according to the member’s plan Evidence of Coverage. Benefit determination is the process by which claims information is matched with product and benefit information to confirm whether the services delivered are covered under the terms of the member’s defined health benefits and apply all the corresponding benefit adjudication rules.

This chapter has two sections:

  • Business user information
  • Technical details

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