Adverse Benefits Determination definition

Adverse Benefits Determination means any denial, reduction or termination of Benefits by Delta Dental for which a Claim has been filed.
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Adverse Benefits Determination means any denial of a request for benefits or any rescission or termination of benefits, in each case in whole or in part, all as more specifically described in the Department of Labor regulations, specifically, 29 C.F.R. § 2560.503-7(m)(4).
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Adverse Benefits Determination means any denial, reduction or termination of Benefits by
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Examples of Adverse Benefits Determination in a sentence

  • External ReviewStandard External Review: If the claimant has exhausted internal appeal reviews, an external review by an Independent Review Organization (IRO) may be requested for review of an Adverse Benefit Determination or Final Internal Adverse Benefits Determination which was based on a judgment as to the Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of the health care Service or treatment.

  • For all Prospective, Concurrent and Retrospective Assessments of a Non-Administrative Adverse Benefits Determination, the notice shall be made as soon as practical considering medical circumstances, but in no case later than 30 calendar days after the Company’s receipt of the request for review.

  • You will not be charged any fees if the Bank declines to authorize a debit card payment transaction or ATM withdrawal.

  • Piedmont will make a preliminary determination as to whether the Adverse Benefits Determination is eligible for an external appeal.

  • The individual who decides the appeal will not have been involved in the previous Adverse Benefits Determination with respect to the claim.

  • A Notice of Adverse Benefits Determination, issued pursuant to Section 1850.210(g), shall 375 specify the following: 376 (1) The reason that the medical necessity criteria were not met, including a citation of the 377 applicable regulation.

  • This is considered an Adverse Benefits Determination and the written notice must include the reasons for not recommending CLIP and an outline of recommendations for alternative less restrictive services for the youth.

  • The Notice of Adverse Benefits Determination, issued pursuant to Section 1850.210(a)-(e) shall 358 contain the following information: 359 360 1.

  • If services are not delivered in accordance with the individual’s plan, an addendum must be completed (see also “PCP Addendum Procedure” QI.2.23) and a notice of Adverse Benefits Determination must be sent to the individual at least twelve (12) days before the change is to occur indicating their services are being reduced, suspended, or terminated (see also “Appeals and Grievance Procedure” RR.2.36).2.

  • If service delivery cannot occur in accordance with the consumer’s IPOS (for example the consumer has been hospitalized, is out of state, etc.), the following guidelines shall be used by staff:▪ If the consumer is hospitalized or out-of-area for up to one (1) month, it is not necessary to addend the IPOS or generate a notice of Adverse Benefits Determination, since the situation is short-term and temporary.


More Definitions of Adverse Benefits Determination

Adverse Benefits Determination 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 any of the following:
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Related to Adverse Benefits Determination

  • Adverse Benefit Determination means any of the following:

  • Administrative merits determination means certain notices or findings of labor law violations issued by an enforcement agency following an investigation. An administrative merits determination may be final or be subject to appeal or further review. To determine whether a particular notice or finding is covered by this definition, it is necessary to consult section II.B. in the DOL Guidance.

  • Final Adverse Benefit Determination means an adverse benefit determination that is upheld at the completion of a health plan issuer’s internal appeals process.

  • Final Internal Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by BCBSTX at the completion of BCBSTX’s internal review/appeal process.

  • Expert Determination the process described in Paragraph 6 of Schedule 8.3 (Dispute Resolution Procedure);

  • Self-Determination means a philosophy and process by which individuals with developmental disabilities are empowered to gain control over the selection of support services that meet their needs. The basic principles of self-determination are:

  • Claim Determination Period means a calendar year. However, it does not include any part of a year during which a person has no coverage under This Plan, or any part of a year before the date this COB provision or a similar provision takes effect.

  • Disability benefit recipient means a member who is receiving a disability benefit.

  • Eligibility Determination means an approval or denial of eligibility and a renewal or termination of eligibility as set forth in OAR 410-200-0015;¶

  • Claim for Benefits means a request for a Plan benefit or benefits made by a Member in accordance with the Plan’s Appeals Procedures, including any Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests for benefit payment).

  • Adverse determination shall have the meaning set forth in Section 19.7.

  • Event Determination Date means either:

  • Disability benefits means any cash payments which are payable to a covered individual for all or part of a period of disability pursuant to P.L.1948, c.110 (C.43:21-25 et al.).

  • Specific learning disability (SLD) means a heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia.

  • TIA Applicability Determination As defined in Section 12.12.

  • Child custody determination means a judgment, decree, or other order of a court providing for the legal custody, physical custody, or visitation with respect to a child. The term includes a permanent, temporary, initial, and modification order. The term does not include an order relating to child support or other monetary obligation of an individual.

  • Monthly Report Determination Date The meaning specified in Section 10.7(a).

  • SOFR Determination Date has the meaning specified in the definition of “Daily Simple SOFR”.

  • specific learning disabilities means a heterogeneous group of conditions wherein there is a deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read, write, spell, or to do mathematical calculations and includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia;

  • Flood Elevation Determination means a determination by the Administrator of the water surface elevations of the base flood, that is, the flood level that has a one percent or greater chance of occurrence in any given year.

  • Final Determination Date means the following:

  • Standard of Conduct Determination shall have the meaning ascribed to it in Section 9(b) below.

  • Adverse employment action means an action that affects an em- ployee ’s compensation, promotion, transfer, work assignment, or performance evaluation, or any other employment action that would dissuade a reasonable employee from making or supporting a report of abuse or neglect under Family Code 261.101.

  • Distribution Determination Date means, in respect of any Distribution Period, that number of business days prior thereto as is set out in the applicable Pricing Supplement or on the face of the relevant Perpetual Security;

  • Determination of Taxability means and shall be deemed to have occurred on the first to occur of the following:

  • Payment Determination Date means, with respect to any Payment Date, one (1) Business Day immediately preceding such Payment Date.