{"component": "definition", "props": {"groups": [{"snippet_links": [{"key": "utilization-review-entity", "type": "definition", "offset": [48, 73]}], "samples": [{"hash": "1TM58OEGqp6", "uri": "https://legacylis.virginia.gov/cgi-bin/legp604.exe?991+ful+SB1235+pdf", "label": "legacylis.virginia.gov", "score": 18.2562334737, "published": false}, {"hash": "eqXLhvZCpfM", "uri": "https://legacylis.virginia.gov/cgi-bin/legp604.exe?001+ful+SB529+pdf", "label": "legacylis.virginia.gov", "score": 18.0651571032, "published": false}, {"hash": "39fo6zzAiCF", "uri": "https://legacylis.virginia.gov/cgi-bin/legp604.exe?001+ful+SB529ER+pdf", "label": "legacylis.virginia.gov", "score": 18.0286898007, "published": false}], "size": 31, "snippet": "means a utilization review determination by the utilization review entity that a", "hash": "48171ba1076a01b5e41e6ac69bc7bd19", "id": 1}, {"snippet_links": [], "samples": [{"hash": "iohRZFuug2A", "uri": "https://www.ilga.gov/legislation/legisnet92/hbgroups/PDF/920HB2492.pdf", "label": "www.ilga.gov", "score": 16.8187563319, "published": false}, {"hash": "hjnoGXnL8EK", "uri": "https://ilga.gov/legislation/102/HB/PDF/10200HB0159lv.pdf", "label": "ilga.gov", "score": 10.5331964408, "published": false}, {"hash": "arUwXYX84AT", "uri": "http://www.ilga.gov/legislation/fulltext.asp?DocName=09300HB5164ham002&GA=93&SessionId=3&DocTypeId=HB&DocNum=5164&GAID=3", "label": "www.ilga.gov", "score": 10.1704312115, "published": false}], "size": 25, "snippet": "means a decision reducing,", "hash": "e6243f54258215adaac57a5821648de9", "id": 2}, {"snippet_links": [{"key": "review-agent", "type": "definition", "offset": [24, 36]}], "samples": [{"hash": "7EinKVphi6F", "uri": "http://webserver.rilin.state.ri.us/billtext/billtext17/housetext17/h5175aaa.pdf", "label": "webserver.rilin.state.ri.us", "score": 10.3275152192, "published": false}, {"hash": "iNEFanvQ3P3", "uri": "http://webserver.rilin.state.ri.us/BillText15/HouseText15/H5604A.pdf", "label": "webserver.rilin.state.ri.us", "score": 7.7392197125, "published": false}, {"hash": "2x6ckzRpb4i", "uri": "http://198.115.170.67/BillText15/SenateText15/S0422A.pdf", "label": "198.115.170.67", "score": 7.720054757, "published": false}], "size": 25, "snippet": "means any decision by a review agent not to certify an admission,", "hash": "ead7ab3884951a88d1ec720d854c5bd9", "id": 3}, {"snippet_links": [{"key": "utilization-review", "type": "clause", "offset": [8, 26]}], "samples": [{"hash": "kwXbtAxRWjC", "uri": "/contracts/kwXbtAxRWjC#adverse-decision", "label": "Individual Enrollment Agreement for a Qualified Health Plan", "score": 27.7974834971, "published": true}, {"hash": "cczS1UHbTwh", "uri": "/contracts/cczS1UHbTwh#adverse-decision", "label": "In Network Individual Enrollment Agreement", "score": 27.7974834971, "published": true}, {"hash": "babm5PodbUa", "uri": "/contracts/babm5PodbUa#adverse-decision", "label": "Individual Enrollment Agreement", "score": 27.7974834971, "published": true}], "size": 14, "snippet": "means a utilization review determination that:", "hash": "16c39a21b2607ad6ed97a1545a059497", "id": 4}, {"snippet_links": [{"key": "the-director", "type": "clause", "offset": [20, 32]}, {"key": "a-person", "type": "clause", "offset": [52, 60]}, {"key": "proper-person", "type": "definition", "offset": [78, 91]}, {"key": "this-act", "type": "definition", "offset": [114, 122]}], "samples": [{"hash": "iYeHGKt7Yqr", "uri": "https://casapng.gov.pg/admin/images/Civil-Aviation-Act-200084.pdf", "label": "casapng.gov.pg", "score": 11.5708418891, "published": false}, {"hash": "lUcGr9ms3Yv", "uri": "https://casapng.gov.pg/admin/images/Civil-Aviation-Act-2000.pdf", "label": "casapng.gov.pg", "score": 9.7255304586, "published": false}, {"hash": "jEREsXmawXL", "uri": "https://ago.gov.to/cms/images/LEGISLATION/PRINCIPAL/2014/2014-0019/CivilAviationAct_3.pdf", "label": "ago.gov.to", "score": 8.453798768, "published": false}], "size": 10, "snippet": "means a decision of the Director to the effect that a person is not a fit and proper person for any purpose under this Act;", "hash": "b6b891ad61b307a5f412462b904dc4cb", "id": 5}, {"snippet_links": [{"key": "final-order", "type": "definition", "offset": [8, 19]}, {"key": "court-of-appeals", "type": "clause", "offset": [39, 55]}, {"key": "by-any-party", "type": "clause", "offset": [146, 158]}], "samples": [{"hash": "6Lntzoz0U5m", "uri": "https://docs.legis.wisconsin.gov/2021/statutes/statutes/809.pdf", "label": "docs.legis.wisconsin.gov", "score": 9.4969199179, "published": false}, {"hash": "gfbZBGBnXh4", "uri": "https://docs.legis.wisconsin.gov/statutes/statutes/809.pdf", "label": "docs.legis.wisconsin.gov", "score": 9.3518138261, "published": false}, {"hash": "kW1wAMzzGkZ", "uri": "https://www.wicourts.gov/supreme/docs/2007appendixa.pdf", "label": "www.wicourts.gov", "score": 8.4305270363, "published": false}], "size": 9, "snippet": "means a final order or decision of the court of appeals, the result of which is contrary, in whole or in part, to the result sought in that court by any party seeking review.", "hash": "16b87aaab4385b5e58594e5d53ba37c4", "id": 6}, {"snippet_links": [{"key": "private-review-agent", "type": "definition", "offset": [25, 45]}, {"key": "life-insurance", "type": "definition", "offset": [56, 70]}, {"key": "dental-service", "type": "clause", "offset": [85, 99]}, {"key": "medically-necessary", "type": "definition", "offset": [107, 126]}, {"key": "the-service", "type": "clause", "offset": [149, 160]}], "samples": [{"hash": "jBGIuLEu5jB", "uri": "https://mymarkiii.com/mcpsva/wp-content/uploads/sites/270/2024/08/Montgomery-County-Schools-Vision-Cert.pdf", "label": "mymarkiii.com", "score": 16.6357631457, "published": false}, {"hash": "hbUMmFdTYlF", "uri": "https://mymarkiii.com/ccpsva/wp-content/uploads/sites/121/2021/04/010054212_B00010716_EPOL.pdf", "label": "mymarkiii.com", "score": 8.3661875428, "published": false}, {"hash": "biwpM5BOecL", "uri": "https://mymarkiii.com/ccpsva/wp-content/uploads/sites/121/2021/04/010054212C02_B00010716_ECERT.pdf", "label": "mymarkiii.com", "score": 8.3661875428, "published": false}], "size": 8, "snippet": "means a determination by Private Review Agent, Ameritas Life Insurance Corp., that a dental service is not medically necessary and reimbursement for the service is either denied or reduced.", "hash": "5b329fd3667e23a313d0d60c9585eaac", "id": 7}, {"snippet_links": [{"key": "utilization-review", "type": "clause", "offset": [8, 26]}, {"key": "health-insurance-plan", "type": "clause", "offset": [75, 96]}, {"key": "health-care-provider", "type": "definition", "offset": [114, 134]}, {"key": "on-behalf-of", "type": "clause", "offset": [142, 154]}, {"key": "a-proposed", "type": "clause", "offset": [171, 181]}, {"key": "health-care-service", "type": "definition", "offset": [195, 214]}, {"key": "medically-necessary", "type": "definition", "offset": [294, 313]}, {"key": "health-care-treatment", "type": "definition", "offset": [321, 342]}, {"key": "experimental-or-investigational", "type": "definition", "offset": [369, 400]}], "samples": [{"hash": "62V68famd3Q", "uri": "https://www.kslegislature.org/li/s/statute/040_000_0000_chapter/040_022a_0000_article/040_022a_0013_section/040_022a_0013_k.pdf", "label": "www.kslegislature.org", "score": 10.9733059548, "published": false}, {"hash": "d0G4s015eR2", "uri": "http://kslegislature.org/li/m/statute/040_000_0000_chapter/040_022a_0000_article/040_022a_0013_section/040_022a_0013_k.pdf", "label": "kslegislature.org", "score": 9.5154004107, "published": false}, {"hash": "84gD8eiQwF4", "uri": "http://www.kslegislature.org/li_2018/m/statute/040_000_0000_chapter/040_022a_0000_article/040_022a_0013_section/040_022a_0013_k.pdf", "label": "www.kslegislature.org", "score": 8.5188227242, "published": false}], "size": 8, "snippet": "means a utilization review determination by a third-party administrator, a health insurance plan, an insurer or a health care provider acting on behalf of an insured that a proposed or delivered health care service which would otherwise be covered under an insured's contract is not or was not medically necessary or the health care treatment has been determined to be experimental or investigational and:", "hash": "f97ece132a18b09c6a9b071ffec92d35", "id": 8}, {"snippet_links": [{"key": "accrediting-agency", "type": "definition", "offset": [45, 63]}], "samples": [{"hash": "7Io5Y1jPZnx", "uri": "https://www.safetyandquality.gov.au/sites/default/files/2022-05/policy_-_approval_under_the_australian_health_service_safety_and_quality_accreditation_ahssqa_scheme_to_conduct_assessments_may_2022.pdf", "label": "www.safetyandquality.gov.au", "score": 11.1984941821, "published": false}, {"hash": "3mgwulFQXAz", "uri": "https://www.safetyandquality.gov.au/sites/default/files/2021-09/policy_-_approval_under_the_ahssqa_scheme_-_september_2021.pdf", "label": "www.safetyandquality.gov.au", "score": 10.8425735797, "published": false}, {"hash": "fVd2SS1kFa6", "uri": "https://www.safetyandquality.gov.au/sites/default/files/2020-03/policy_approval_under_the_ahssqa_scheme_to_conduct_accreditations_of_health_service_organisations_using_the_shemes_standards_november_2019.pdf", "label": "www.safetyandquality.gov.au", "score": 10.0841889117, "published": false}], "size": 8, "snippet": "means a decision not to grant approval as an accrediting agency, or to suspend or revoke approval as an accrediting agency;", "hash": "b0d75e754db2896e3437638798ebcb0b", "id": 9}, {"snippet_links": [{"key": "medical-staff-membership", "type": "clause", "offset": [87, 111]}, {"key": "clinical-privileges", "type": "definition", "offset": [115, 134]}], "samples": [{"hash": "kDap0rOV4Ch", "uri": "https://ilga.gov/legislation/publicacts/102/PDF/102-0004.pdf", "label": "ilga.gov", "score": 8.6700889802, "published": false}, {"hash": "eNQprQaYhTU", "uri": "http://www.ilga.gov/senate/journals/sfinaljrnls92/pdf/sjf92081_r.pdf", "label": "www.ilga.gov", "score": 8.1704312115, "published": false}, {"hash": "826lT1igeiC", "uri": "https://www.ilga.gov/house/journals/93/2004/HJ093114R.pdf", "label": "www.ilga.gov", "score": 5.0, "published": false}], "size": 6, "snippet": "means a decision reducing, restricting, suspending, revoking, denying, or not renewing medical staff membership or clinical privileges.", "hash": "923b8ec0c2ffe0d059c5690c9ff6f20d", "id": 10}], "next_curs": "Cl0SV2oVc35sYXdpbnNpZGVyY29udHJhY3RzcjkLEhpEZWZpbml0aW9uU25pcHBldEdyb3VwX3Y1NiIZYWR2ZXJzZS1kZWNpc2lvbiMwMDAwMDAwYQyiAQJlbhgAIAA=", "definition": {"size": 246, "snippet": "means a utilization review determination by the utilization review entity that a", "title": "Adverse decision", "id": "adverse-decision", "examples": ["For the purpose of this Section, the following terms have the following meanings: \u2022 &quot;<strong>Adverse decision</strong>&quot; is our utilization review determination that a proposed or delivered Covered Health Service which would otherwise be covered under the Policy is not or was not Medically Necessary, appropriate or efficient, and may result in non-coverage of the health care service."], "related": [["adverse-determination", "Adverse determination", "Adverse determination"], ["key-decision", "key decision", "key decision"], ["final-adverse-determination", "Final Adverse Determination", "Final Adverse Determination"], ["proposed-decision", "Proposed decision", "Proposed decision"], ["final-decision", "Final Decision", "Final Decision"]], "related_snippets": [], "updated": "2025-07-06T21:58:41+00:00"}, "json": true, "cursor": ""}}