Adverse determination definition
Adverse determination means a final action or adjudication that the person or entity in question has committed Wage Theft or Payroll Fraud and is further defined in Chapter 190.
Adverse determination shall have the meaning set forth in Section 19.7.
Adverse determination means a determination by a health maintenance organization or its designee utilization review organization that an admission, availability of care, continued stay or other health care service has been reviewed and, based upon the information provided, does not meet the health maintenance organization’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service is therefore denied, reduced or terminated.
Examples of Adverse determination in a sentence
You must request external review within six months from the date of the Adverse Determination.
If the Adverse Determination is completely reversed, the filing fee must be refunded.
You or your Authorized Representative must file your appeal within 180 days of the Adverse Determination.
We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a phone notice.
We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a telephone notice.
More Definitions of Adverse determination
Adverse determination means a determination by a health
Adverse determination means a determination by an HMO or Utilization Review agent that the Health Care Services furnished, or proposed to be furnished to a patient, are not Medically Necessary or not appropriate.
Adverse determination means a determination made that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.¶
Adverse determination means a determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a covered person are:
Adverse determination means a determination by a health carrier, including an managed care organization or dental benefits manager, or its designee that an admission, availability of care, continued stay or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and the requested service or payment for services is therefore denied, reduced or terminated.
Adverse determination means a utilization review decision by a review agent not to
Adverse determination means a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based on the information provided, does not meet the health carrier's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. Failure to respond in a timely manner to a request for a determination is an adverse determination.