Adverse Determination - Adverse determination definition
Adverse Determination - Adverse determination means any instance in which coverage for the requested service is denied, reduced, or terminated. The contractor’s decision to deny, reduce or terminate coverage must be based on the review of whether an admission, availability of care, continued stay, or other service required in accordance with this contract meets the contractor’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness. Agency - State of Florida, Agency for Health Care Administration. Ancillary Services - Services provided at a hospital include, but are not limited to, radiology, pathology, neurology, and anesthesiology as specified in the Hospital Coverage and Limitations Handbook. Appeal - 42 CFR 438.400 - A request for review of action.
Adverse Determination - Adverse determination means any instance in which coverage for the requested service is denied, reduced, or terminated. The contractor's decision to deny, reduce or terminate coverage must be based on the review of whether an admission, availability of care, continued stay, or other service required in accordance with this contract meets the contractor's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness Agency - State of Florida, Agency for Health Care Administration. Ancillary Services - Services provided at a hospital include, but are not limited to, radiology, pathology, neurology, and anesthesiology as specified in the Hospital Coverage and Limitations Handbook. Area Agency on Aging - an agency designated by the department to develop and administer a plan for a comprehensive and coordinated system of services for older persons. Benefits - a schedule of medical or social services to be delivered to enrollees covered under this contract. CMS - Centers for Medicare and Medicaid Services. Capitation Rate - the monthly fee paid by the agency to the contractor for each enrollees enrolled under the contract for the provision of services during the payment period. CARES - Comprehensive Assessment and Review for Long Term Care Services. A nursing home pre-admission assessment program, which provides a comprehensive, on-site assessment of individuals seeking admission to a nursing home under a state assisted program. The program explores all available options to nursing home placement and recommends, and may facilitate alternative placements for individuals who are determined able to remain in the community. CFR - Code of Federal Regulations.