Adverse Benefit Determination definition

Adverse Benefit Determination means any of the following:

Adverse Benefit Determination means a decision by a health plan issuer:

Adverse Benefit Determination means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of an enrollee's or applicant's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

Examples of Adverse Benefit Determination in a sentence

• The CONTRACTOR shall notify the requesting Provider and provide the Member or authorized representative and the Caregiver a notice of Adverse Benefit Determination when a team involved in the individualized planning process recommends a service for a CISC be reduced, modified, delayed, denied, or not approved within ten (10) Calendar Days of recommendation.

• The SOE must contain copies of all documentation used to make the CONTRACTOR’s decision, and it must explain the reasons for the Adverse Benefit Determination and address all of the Member’s concerns.

• The CONTRACTOR shall mail a notice of Adverse Benefit Determination to the Member or provider in accordance with the procedures and time frames in 42 C.F.R. § 438.404 unless such time frame is prescribed in this Section 4.17.3. The CONTRACTOR shall mail a notice of Adverse Benefit Determination within five (5) Calendar Days if probable Member Fraud has been verified.

• The notice of Adverse Benefit Determination shall be provided to the Member and the Member’s Caregiver, authorized representative, and legal custodian.

• The CONTRACTOR must ensure that the Notice of Adverse Benefit Determination clearly explains the reason for the CONTRACTOR’s decision in plain language and provides sufficient detail to allow the Member to make an informed decision regarding appealing the determination.

More Definitions of Adverse Benefit Determination

Adverse Benefit Determination means a denial, reduction, or

Adverse Benefit Determination means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Participant’s or beneficiary’s eligibility to participate in the Plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or appropriate, or a rescission of coverage if the Plan Administrator determines that the Employee or a Dependent engaged in fraud or intentional misrepresentation of a material fact in order to obtain coverage and/or benefits under the Plan. In such case, the Participant will receive written notice at least thirty (30) days before the coverage is rescinded.

Adverse Benefit Determination means a denial, reduction or the termination of, or a failure to provide or make payment (in whole or in part) with respect to a Claim for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Participant’s or Beneficiary’s eligibility to participate in the Plan.

Adverse Benefit Determination means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in the Plan.

Adverse Benefit Determination means any of the following: a denial, reduction or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a claimant’s eligibility to participate in a plan and with respect to a claim for benefits due to Executive being Permanently Disabled, shall also mean any rescission of disability coverage with respect to a Participant or Beneficiary (whether or not there is an adverse effect on any particular benefit at that time), where rescission means a cancellation or discontinuance of coverage that has retroactive effect, except to the extent it is attributable to a failure to timely pay required premiums or contributions towards the cost of coverage.

Adverse Benefit Determination. Means denial or partial denial of a Benefit, in whole or in part, based on:

Adverse Benefit Determination means an insurer’s denial, reduction or termination of a