Final Adverse Benefit Determination definition

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

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Final Adverse Benefit Determination means the upholding of an Adverse Benefit Determination at the conclusion of the internal appeals process or an Adverse Benefit Determination in which the internal appeals process has been deemed exhausted.

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

Examples of Final Adverse Benefit Determination in a sentence

• If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.

• You may contact an Alliant Complaints and Appeals Coordinator at the number listed on the acknowledgement letter or notice of Adverse Benefit Determination or Final Adverse Benefit Determination.

• To request an expedited review of an Adverse Benefit Determination or Final Adverse Benefit Determination the Member may call Customer Services at ▇-▇▇▇-▇▇▇-▇▇▇▇ (TTY: 711).

• External review is available for appeals from an Adverse Benefit Determination or Final Adverse Benefit Determination that involves medical judgment (including, decisions based on the HMO’s requirements for Medical Necessity and appropriateness, heath care setting, level of care or effectiveness of a covered benefit as well as the HMO’s treatment is experimental /investigational or cosmetic.

• Your notice of Adverse Benefit Determination and Final Adverse Benefit Determination describes the process to follow if you wish to pursue an external appeal.

More Definitions of Final Adverse Benefit Determination

Final Adverse Benefit Determination means the upholding of an Adverse Benefit Determination at the conclusion of the internal appeals process or an Adverse Benefit Determination in which the internal appeals process has been deemed exhausted. External Review is only available for a Final Adverse Benefit Determination based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness of a Covered Service.

Final Adverse Benefit Determination means an Adverse Benefit Determination that has been upheld by the Plan at the completion of the Plan’s appeals procedure or an Adverse Benefit Determination for which the Plan’s appeals procedures were not properly followed.

Final Adverse Benefit Determination means an Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Alliant, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.

Final Adverse Benefit Determination means an ABD upheld at the completion of a health plan issuer’s internal appeals process.

Final Adverse Benefit Determination means an Adverse Benefit Determination issued in connection with the last stage of Appeal as set forth in the Appeals Section.

Final Adverse Benefit Determination means an adverse benefit determination that has been upheld by a carrier at the completion of the carrier's internal review process.

Final Adverse Benefit Determination means any claims denial, or partial de- nial, upheld by the Trustees, or by their claims review committee, upon ap- peal.