Adverse Benefit Determinations. An adverse benefit determination is any of the following: • Denial of a benefit (in whole or part), • Reduction of a benefit, • Termination of a benefit, • Failure to provide or make a payment (in whole or in part) for a benefit, • Denial, reduction, termination, or failure to make a payment based on the imposition of a preexisting condition exclusion, a source of injury exclusion, or other limitation on covered benefits, and • Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is at (000) 000-0000 or 0-000-000-0000.
Adverse Benefit Determinations. Insurer shall provide timely and adequate written notice of an Adverse Benefit Determination. The benefit determination and any notice of Adverse Benefit Determination must be provided within the following timeframes in accordance with 42 CFR 457.1260 and to the extent it incorporates 42 CFR part 438 subpart F:
Adverse Benefit Determinations. An adverse benefit determination is any of the following: Denial of a benefit (in whole or part), Reduction of a benefit, Termination of a benefit, Failure to provide or make a payment (in whole or in part) for a benefit, and Rescission of coverage, even if there is no adverse effect on any benefit. An appeal of an adverse benefit determination can be made either as an administrative appeal or as a medical appeal, as defined further in this section. Our Customer Service Department phone number is at (000) 000-0000 or 0-000-000-0000.
