Adverse Decision Sample Clauses
Adverse Decision for the purposes of these Appeals procedures (and ERISA, as applicable), means a denial in whole or in part of a Pre-Service Claim or a Post-Service Claim and for which You are financially responsible or, for a Pre-Service Claim, for which You would be financially responsible, if You obtained the service. Adverse Decision, for the purposes of External Review procedures, is limited to the definition of Adverse Decision Eligible for External Review. Adverse Decision also means any retroactive cancellation of coverage other than for non-payment of premium.
Adverse Decision. Any determination by Health Plan that:
Adverse Decision. If an adverse decision on the Contractor’s formal contract claim has been rendered by the County’s purchasing manager, the notice of decision shall inform the Contractor of the right to request mediation.
Adverse Decision. If an adverse decision on the Licensee’s formal contract claim has been rendered by the Building Owner’s purchasing manager, the notice of decision shall inform the Licensee of the right to request mediation.
Adverse Decision. For adverse appeal determinations, the notification shall reflect at least the following:
(1) state the specific reason(s) for determination;
(2) reference specific Plan provision(s) upon which the determination is based;
(3) describe Plan procedures and time limits for appeal of the determination, and the right to obtain information about those procedures and the right to sue in federal court;
(4) disclose any internal rules, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request);
(5) a statement indicating entitlement to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; and
(6) where the decision involves scientific or clinical judgment, disclose either (1) an explanation of the scientific or clinical judgment applying the terms of the Plan to claimant’s medical circumstances, or (2) a statement that such explanation will be provided at no charge upon request. Notice of the adverse determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with applicable legal requirements.
Adverse Decision. If an adverse decision on the CHLIC’s formal contract claim has been rendered by the Employer’s purchasing manager, the notice of decision shall inform the CHLIC of the right to request mediation.
Adverse Decision. For adverse claim determinations, the notification shall reflect at least the following:
(1) state the specific reason(s) for determination;
(2) reference specific Plan provision(s) upon which the determination is based;
(3) describe additional material or information necessary to complete the claim and why such information is necessary;
(4) describe Plan procedures and time limits for appeal of the determination, and the right to obtain information about those procedures and the right to sue in federal court;
(5) disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request); and
(6) where the decision involves scientific or clinical judgment, disclose either: (i) an explanation of the scientific or clinical judgment applying the terms of the Plan to claimant’s medical circumstances, or (ii) a statement that such explanation will be provided at no charge upon request. Notice of the adverse determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with applicable legal requirements.