Adverse Determinations Clause Samples

Adverse Determinations. An adverse determination notification as the result of notification requirements or a concurrent medical review will: (A) be issued by a medical director only after the medical director has contacted and discussed the case with the ordering physician or designee (or made a reasonable attempt to contact); (B) include a substantive clinical justification that is consistent with generally accepted principles of professional medical practice; (C) identify the specific information upon which the adverse determination was based; (D) discuss the Customer's presenting symptoms or condition, diagnosis and treatment interventions and the specific reasons such medical evidence fails to meet the relevant medical review criteria; (E) specify any alternative treatment option offered by us, if any; (F) reference and include applicable clinical practice guidelines and review criteria; (G) specify whether or not a Customer has any liability; (H) include appeal and reconsideration rights.

Adverse Determinations. In the event of an Adverse Determination, HMO shall notify the Member or a person acting on behalf of the Member and the Member’s provider of record of an Adverse Determination. The notification shall include the following: • the principal reasons for the Adverse Determination; • the clinical basis for the Adverse Determination; • notification to the Member of the Member’s right to appeal Adverse Determination to an independent review organization; • notification to the Member of the procedures for appealing an Adverse Determination to an independent review organization; and • notification to a Member who has a life-threatening condition of the Member’s right to an immediate review by an independent review organization and the procedures to obtain that review.

Adverse Determinations. Materially adverse determination in any litigation, action, proceeding before any court or governmental body (domestic or foreign) relating to MSI or its Subsidiaries or to the best of MSI's knowledge, TMSI and their respective businesses, assets or properties;