Adverse benefit definition

Adverse benefit determinations” are decisions made by HMO that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service or termination of a Member's coverage back to the original effective date (rescission). Such adverse benefit determination may be based on: • Your eligibility for coverage. • Coverage determinations, including plan limitations or exclusions. • The results of any Utilization Review activities. • A decision that the service or supply is an Experimental or Investigational Procedure. • A decision that the service or supply is not Medically Necessary. A “final adverse benefit determination” is an adverse benefit determination that has been upheld by Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. As soon as possible, but not later than 72 hours after the claim is made. If more information is needed to make an Urgent Care Claim decision, HMO will notify the claimant within 72 hours of receipt of the claim. The claimant has 48 hours after receiving such notice to provide HMO with the additional information. HMO will notify the claimant within 48 hours of the earlier to occur: • the end of the 48 hour period given the Physician to provide HMO with the information. Within 15 calendar days. HMO may determine that due to matters beyond its control an extension of this 15-calendar day claim decision period is required. Such an extension, of not longer than 15 additional calendar days, will be allowed if HMO notifies the Member within the first 15 calendar day period. If this extension is needed because HMO needs more information to make a claim decision, the notice of the extension shall specifically describe the required information. The Member will have 45 calendar days, from the date of the notice, to provide HMO with the required information. Concurrent Care Claim Extension. A request to extend a course of treatment previously pre-authorized by HMO. If an urgent care claim as soon as possible, but not later than 24 hours provided the request is received at least 24 hours prior to the expiration of the approved course of treatment. A decision will be provided not later than 15 calendar days with respect to all other care, following a...

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Adverse benefit determinations” are decisions made by HMO that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service or termination of a Member's coverage back to the original effective date (rescission). Such adverse benefit determination may be based on: • Your eligibility for coverage. • Coverage determinations, including plan limitations or exclusions; except when the Member presents evidence from a medical professional that there is a reasonable medical basis that the exclusion does not apply to the denied benefit. • The results of any Utilization Review activities. • A decision that the service or supply is an Experimental or Investigational Procedure. • A decision that the service or supply is not Medically Necessary. A “final adverse benefit determination” is an adverse benefit determination that has been upheld by HMO at the exhaustion of the Appeals process. HMO Timeframe for Notification of a Benefit Determination Urgent Care Claim. A claim for medical care or treatment where delay could seriously jeopardize the life or health of the Member, the ability of the Member to regain maximum function; or subject the Member to severe pain that cannot be adequately managed without the requested care or treatment. As soon as possible, but not later than 72 hours Within 15 calendar days Concurrent Care Claim Extension. A request to extend a course of treatment previously pre-authorized by HMO. If an Urgent Care claim as soon as possible, but not later than 24 hours. Otherwise, within 15 calendar days Concurrent Care Claim Reduction or Termination. Decision to reduce or terminate a course of treatment previously pre-authorized by HMO. With enough advance notice to allow the Member to Appeal Within 30 calendar days As to a Concurrent Care Claim Reduction or Termination, if the Member files an Appeal, Covered Benefits under the Certificate will continue for the previously approved course of treatment until a final Appeal decision is rendered. During this continuation period, the Member is responsible for any Copayments and Deductibles that apply to the services; supplies; and treatment; that are rendered in connection with the claim that is under Appeal. If HMO's initial claim decision is upheld in the final Appeal decision, the Member will be responsible for all charges incurred for services; supplies; and treatment; received during this continuation period.

Examples of Adverse benefit in a sentence

• Adverse benefit determination (action) means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s eligibility to participate in a plan.

• Adverse benefit determinations, including rescissions of coverage, and their appeals are subject to the requirements of Section 2719 of the PHSA, as added by PPACA, and applicable regulations to include 45 CFR 147.136 and 29 CFR 2560.503-1.

• Adverse benefit determinations that are not grievances will follow standard ACA internal appeals processes.

• Adverse benefit determinations are decisions made by the HMO that result in denial, reduction, or termination of a benefit or the amount paid for it.

• Adverse benefit determinations can be made for one or more of the following reasons: • Utilization Review.

• Adverse benefit determination notices pursuant to claim denials must be sent on the date of claim denial.

• Adverse benefit determination notices involving service authorization request decisions that deny or limit services must be made within the time frames described in this Contract.

• Adverse benefit determinations can be made for one or more of the following reasons: • No Coverage.

• Adverse benefit determination also means a decision not to provide or to modify or delay a benefit or service.

• Adverse benefit determination does not include any of the following: When the WI FCMH, provider, or subcontractor triages a member to a proper health care provider; or When an individual health care provider determines that a service is medically unnecessary.