Common use of Adverse Determinations Clause in Contracts

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. 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 CustomerMember'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 Member has any liability; (H) include appeal and reconsideration rights.