Common use of Adverse Benefit Determination Related to Requests for Services and Coverage Denials Clause in Contracts

Adverse Benefit Determination Related to Requests for Services and Coverage Denials. The Contractor shall provide the Enrollee written notice that meets the language and formatting requirements for Enrollee materials, of any Adverse Benefit Determination (not limited to service authorization actions) within the timeframes for each type of Adverse Benefit Determination pursuant to 42 C.F.R. 438.210(d) and in compliance with 42 C.F.R. 438.404 and other provisions of this Contract. The notice must explain:

Adverse Benefit Determination Related to Requests for Services and Coverage Denials. The Contractor shall provide the Enrollee Member written notice that meets the language and formatting requirements for Enrollee Member materials, of any Adverse Benefit Determination adverse benefit determination (not limited to just service authorization actions) within the timeframes for each type of Adverse Benefit Determination adverse benefit determination pursuant to 42 C.F.R. CFR 438.210(d) and in compliance with 42 C.F.R. CFR 438.404 and other provisions of this Contract. The notice must explain: