Adverse determination definition

Adverse determination means a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, based on a determination of a member’s eligibility to participate in the Plan, and including a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. An Adverse Determination does not mean a determination that the healthcare services are not covered services. The Plan Manager is responsible for the Internal Appeal Process for Adverse Determinations in accordance with KRS 304.17A-600 through 633.
Adverse determination shall have the meaning set forth in Section 19.7.

Examples of Adverse determination in a sentence

  • Definitions "Adverse determination" means any denial, reduction or termination of a benefit or failure to provide or make payment (in whole or in part) for a benefit.

  • ADVERSE DETERMINATION Adverse determination means a determination made in accordance with sections 1919(b)(3)(f) or 1919(e)(7)(B) of the Act that the individual does not require the level of services provided by a NF or that the individual does or does not require specialized services.

  • These procedures are the minimum requirements for benefit claims procedures of employee benefit plans covered by Title 1 of the Employee Retirement Income Security Act of 1974 ("ERISA") Definitions "Adverse determination" means any denial, reduction or termination of a benefit or failure to provide or make payment (in whole or in part) for a benefit.

  • The location of the information deleted and the exemption(s) under which the deletion is made will be indicated directly on the record itself, if technically feasible.(2) Adverse determination of requests.If a determination is made to deny a request in any respect, HUD shall notify the requester of that determination in writing.

  • Adverse determination or denials of request may include decisions that: the requested records are exempt in whole or in part; the request does not reasonably describe the records sought; the information requested is not a record subject to the FOIA; the requested records do not exist, cannot be located or have been destroyed; or the requested record is not readily reproducible in the form or format sought by the requester.


More Definitions of Adverse determination

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 or on behalf of an insurer that issues a health benefit plan to which all of the following apply:
Adverse determination shall have the meaning set forth in Section 19.7(b) hereof.
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 has been reviewed and has been denied, reduced, or terminated. Failure to respond in a timely manner to a request for a determination constitutes an adverse determination.
Adverse determination means a utilization review decision by a review agent not to
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.