Final Internal Adverse Benefit Determination definition

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by BCBSTX at the completion of BCBSTX’s internal review/appeal process.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by HMO at the completion of HMO’s internal review/appeal process.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Claim Administrator or, if applicable, your Employer, at the completion of the internal review/appeal process of an Adverse Benefit Determination with respect to which the internal review/appeal process has been deemed exhausted.

Examples of Final Internal Adverse Benefit Determination in a sentence

• Further a Member is entitled to an expedited review if the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay or health care service for which the Member received Emergency Services but has not been discharged from a facility.

• The Member may request an expedited external review of an Adverse Benefit Determination as well as from a Final Internal Adverse Benefit Determination if the Member’s condition involves a medical condition for which the timeframe for completion of a standard review would seriously jeopardize the Member’s life or health or would jeopardize the Member’s ability to regain maximum function.

• If a Member is not satisfied upon receiving the Final Internal Adverse Benefit Determination, he or she has four (4) months from receipt to request an external appeal through an Independent Review Organization (IRO).

• If the Member is not satisfied with the result of the expedited review, they may seek an expedited external review of the Final Internal Adverse Benefit Determination.

• The HMO will conduct an expedited internal review and issue its Final Internal Adverse Benefit Determination within (72) hours of receipt of the request which qualifies for an expedited review.

More Definitions of Final Internal Adverse Benefit Determination

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Claim Administrator or your Employer at the completion of the Claim Administrator's or Employer's internal review/appeal process.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Plan at the conclusion of the internal claims and appeals process, or an Adverse Benefit Determination with respect to which the internal claims and appeals process has been deemed exhausted.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by Blue Cross and Blue Shield at the completion of the Blue Cross and Blue Shield's internal review/appeal process.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by Us at completion of Our internal review/appeal process.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Claim Administrator at the completion of the Claim Administrator's internal review/appeal process.

Final Internal Adverse Benefit Determination means an adverse benefit determination that has been upheld by a health plan or carrier at the completion of the internal appeals process, or an adverse benefit determination with respect to which the internal appeals process has been exhausted under the exhaustion rules described in RCW 48.43.530 and 48.43.535.

Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Plan at the completion of the internal review/appeal process.