Notice of Adverse Benefit Determination i. The Contractor shall notify the requesting provider, and give the beneficiary written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The beneficiary’s notice shall meet the requirements of 42 CFR §438.404.
Notice of Adverse Benefit Determination. In accordance with Article XI, Section D.1., the MCO shall provide written notice of an adverse benefit determination to the member when a decision is made to: Deny or limit a member’s request for a service in the benefit package; Terminate, reduce, or suspend any currently authorized service; or Deny payment for services in the benefit package. Notification of Non Covered Benefit In accordance with Article XI, Section D.1., the MCO shall provide a Notification of Non Covered Benefit (xxxxx://xxx.xxx.xxxxxxxxx.xxx/library/f-01283.htm) to the member when a decision is made to: Deny a member’s request for a service outside the benefit package; or Deny a member's request for payment of a service outside of the benefit package.
Notice of Adverse Benefit Determination. Notices of adverse benefit determinations must adhere to the content and timeframe requirements detailed in the Member Grievances and Appeals Guide.
Notice of Adverse Benefit Determination. In accordance with Article XI, Section D.1, the PO shall provide written notice of an adverse benefit determination to the member when a decision is made to: Deny or limit a member’s request for a service ; Terminate, reduce, or suspend any currently authorized service; or Deny payment for services.
Notice of Adverse Benefit Determination. A written notice from the Contractor to a member to advise the member of an Adverse Benefit Determination. A Notice of Adverse Benefit Determination shall comply with the requirements in Section 3.15.2 of this Contract.
Notice of Adverse Benefit Determination. Great Rivers is responsible for issuing Notice of Adverse Benefit Determination, to the Individual or their Representative, in accordance with 42 CFR § 438.404 and WAC 000-000-0000.
Notice of Adverse Benefit Determination is a written notice a BHO provides to an individual to communicate an adverse benefit determination.
Notice of Adverse Benefit Determination. The CONTRACTOR must notify the requesting Provider, and give the Member written notice of any decision by the CONTRACTOR to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements set forth in 42 C.F.R. part 438, subpart F and the Managed Care Policy Manual. The CONTRACTOR must ensure that the Notice of Adverse Benefit Determination clearly explains the reason for the CONTRACTOR’s decision in plain language and provides sufficient detail to allow the Member to make an informed decision regarding appealing the determination. If the reason for the Adverse Benefit Determination is the lack of necessary information, the written notice must clearly explain what information is needed and how and when to provide the necessary information. The CONTRACTOR shall notify the requesting Provider and provide the Member or authorized representative and the Caregiver a notice of Adverse Benefit Determination when a team involved in the individualized planning process recommends a service for a CISC be reduced, modified, delayed, denied, or not approved within ten (10) Calendar Days of recommendation. The notice of Adverse Benefit Determination shall be provided to the Member and the Member’s Caregiver, authorized representative, and legal custodian. CYFD will be the authorized representative for these children. For children fourteen (14) years and older, notices will go the Member, Member’s Caregiver, authorized representative, and legal custodian. The Member’s authorized representative, Caregiver, and legal custodian will be identified by the child with their PPW. Self-Directed Community Benefit (SDCB)
Notice of Adverse Benefit Determination. (NOABD) means a formal communication to the 26 Medi-Cal beneficiary of any action regarding their Drug Medi-Cal services and their right to appeal, 27 consistent with 42 CFR 438.404 and 438.10.
Notice of Adverse Benefit Determination is a written notice provided to an individual to communicate an adverse benefit determination.
